Attachment 1d - ICRA.pdf

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Infection Control Risk Assessment and Permit

Work Location/Description:

Start Date End Date

Project Manager Name / Phone Number :

TYPE A:

TYPE B:

TYPE C:

TYPE D:

Low Risk

Medium Risk

High Risk

Highest Risk

Identify Any Adjacent High Risk Areas:

Above Below Front Behind Lateral NA

CLASS 1 1 Minimize raising dust from construction operations 2 Immediately replace any ceiling tile displaced for visual inspection.

CLASS II 1 Minimize raising dust by water misting work surfaces to control dust while cutting.

2 Seal unused doors with duct tape.

3 Block off and seal air vents with plastic or impervious material.

4 Wipe surfaces with cleaner/disinfectant.

5 Isolate HVAC system in areas where work is being performed

6 Contain construction waste prior to transport in tightly covered containers.

7 Wet mop and/or vacuum with HEPA-filtered vacuum prior to leaving area.

8 Remove critical barrier(s) carefully to minimize spread of dirt/debris.

9 Use hospital-approved disinfectant 10 Place dust mat at entrance and exit of work area.

11 Restore HVAC when work completed.

CLASS III 1 Isolate HVAC system in area of work to prevent contamination of the duct system.

2 Complete all critical barriers or implement control cube or other method prior to work.

3 Maintain negative air pressure within work environment with HEPA-equipment.

4 Do not remove barriers from site until completed project is checked by infection Control.

5 Environmental Services thoroughly cleans.

6 Vacuum work with HEPA-filtered vacuum.

7 Wet mop with hospital approved cleaner/disinfectant.

8 Remove barrier materials carefully to minimize spread of dirt/debris.

9 Contain construction waste prior to transport in tightly covered containers.

10 Cover transport receptacles or carts.

11 Tape coverings.

12 When complete, restore HVAC system where work was performed.

CLASS IV 1 Isolate HVAC system in work area to prevent contamination of duct system.

2 Complete all critical barriers or use control cube method prior to start of construction.

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

4 Seal holes, pipes, conduits, and punctures.

5 Construct anteroom and require all personnel to pass through this room so they can be vacuumed off using a HEPA vacuum cleaner before leaving work site, or wear protective paper coveralls (bunny suit) that is removed each time leaving the work site.

6 Require all personnel entering work site to wear shoe covers.

7 Do not remove barriers from work site until project is checked by Infection Control; and is thoroughly cleaned by environmental services.

8 Vacuum work area with HEPA-filtered vacuums.

9 Wet mop with hospital–approved disinfectant.

10 Remove barrier(s) carefully to minimize spread of dirt/debris associated with construction.

11 Contain construction waste prior to transport in tightly covered containers.

12 Cover transport receptacles or cart.

13 Tape coverings.

14 At completion, restore HVAC system where work was performed.

Is permit required to be posted onsite? _________YES _________NO

Permit Requested By Signature / Date Infection Control Signature / Date

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Class Determination

RISK GROUP TYPE A TYPE B TYPE C TYPE D

LOW Risk Class 1 Class II Class II Class III/IV

MEDIUM Risk Class 1 Class II Class III Class IV

HIGH Risk Class 1 Class II Class III/IV Class IV

HIGHEST Risk Class II Class III/IV Class III/IV Class IV

Risk Groups

Low Risk

Office areas, Maintenance, Housekeeping, Storage Areas, Stairwells, Storage buildings, Warehouse, Library, Meeting Rooms, Staff Lounges, Empty Patient Rooms

Medium Risk Clinical Areas (Not Otherwise Listed), Outpatient Services (Not Otherwise Listed), Physical Therapy, Radiology, Dental, Behavioral Health, Same Day Surgery, Cafeteria, Snack Bar

Medium High Risk

Emergency Room, Laboratories, Pharmacy, Occupied Patient Rooms, Inpatient Departments, Food Preparation Areas, Nursery, PACU, Above Ceiling Work in Open Interstitial Space within 100 Linear Feet of Group III/IV, Labor and Delivery, Medication Rooms.

Highest Risk Sterile Areas, Segregated Compound Area (IV Room), Containment Segregated Compounding Area (Chemo), Airborne Isolation, Sterile Supply, Operating Rooms, C- Section Operating Rooms, Endoscopy, Intensive Care, Oncology Infusion.

Project Type

TYPE A Inspection and non-invasive activities

Removal of ceiling tiles for visual inspection only ( limited to one tile per 50 square feet)

Painting, not sanding

Wallcovering, electrical trim work, minor plumbing, and activities that do not general dust or require cutting of walls or access to ceiling other than for visual inspection

TYPE B Small-scale, short duration activities that create minimal dust

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 moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies

Sanding of walls for painting or wall coverings

Removal of floor covering, ceiling tiles, and case work

New wall construction

Minor duct work or electrical work above ceiling

Major cabling activities

Activities that cannot be completed in a single work shift

TYPE D Major demolition and construction projects

Activities that require consecutive work shifts

Required heavy demolition or removal of a complete cabling system

New Construction