Attachment 2 Infection Control Risk Assessment ICRA.pdf

Name:

Date:

Infection Control Risk Assessment (ICRA)

Manchester VAMC

1: Identify Activities 1.1: Identify the Patient Risk Groups. If more than one risk group will be affected, select the higher risk group that applies. *

1.2: Match your selected Patient Risk Group with Construction Activity Type using the ICRA Matrix to determine Precaution Class. Select the Precaution Class number below. (Take note and remember your selection for the next section). *

1.2.1: Class I

1.2.2: Class II

1.2.2.1: Class II Complete

1.2.3: Class III

1.2.3.1: Class III Complete

1.2.4: Class IV

1.2.4.1: Class IV Complete 1.3: Identify the Construction Activity Type *

1.3.1: 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)Wallcovering, 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.

1.3.2: Type B: Small scale, short duration activities which create minimal dust.Includes, but is not limited to:Installation of telephone and computer cablingAccess to chase spacesCutting of walls or ceiling where dust migration can be controlled

1.3.3: Type C: Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assembliesIncludes, but is not limited to:Sanding of walls for painting or wall coveringRemoval of floor coverings, ceiling tiles and case workNew wall constructionMinor duct work or electrical work above ceilingsMajor cabling activitiesAny activity, which cannot be completed within a single work shift

Infection Control Risk Assessment (ICRA) 1Continued on the next page.

1.3.4: Type D: Major demolition and construction projectsIncludes, but is not limited to:Activities which require consecutive work shiftsRequires heavy demolition or removal of a complete cabling systemNew construction 1.4: Water Shutdown *

1.4.1: Days *

1.4.1.1: Flush 1.5: Project/WO Number * 1.5.1: Project Name *

1.6: Project COR/Lead *

2: Identify Areas Surrounding Project Area 2.1: Unit Below

2.1.1: Risk Group

2.2: Unit Above

2.2.1: Risk Group

2.3: Lateral

2.3.1: Risk Group

2.4: Lateral

2.4.1: Risk Group

2.5: Behind

2.5.1: Risk Group

2.6: Front

2.6.1: Risk Group

3: Description

Infection Control Risk Assessment (ICRA) 2Continued on the next page.

3.1: Describe activity and identify specific site of activity, e.g., patient rooms, medication room, etc.

3.2: Identify issues related to: ventilation, plumbing, electrical, in terms of the occurrence of probable outages.

3.3: Identify containment measures using prior assessment. What type of barriers, e.g., solid wall barriers? Will HEPA filtration be required? (Note:

Renovation/construction area shall be isolated from the occupied areas during construction.)

3.4: Consider potential risk of water damage. Is there a risk due to compromising structural integrity, e.g., wall, ceiling and roof?

3.5: Work hours: Can or will the work be done during non-patient care hours?

3.6: Do plans allow for adequate number of isolation / negative airflow rooms?

Infection Control Risk Assessment (ICRA) 3Continued on the next page.

3.6.1: Specify Number

3.7: Do the plans allow for the required number & type of hand washing sinks?

3.7.1: Specify Number of Sinks

3.8: Describe plans relative to clean and soiled utility rooms.

3.9: Describe the following containment issues and plan to discuss with the project team: traffic flow, housekeeping, debris removal (how and when).

4: Points of Contact 4.1: Project COR Name (Last, First) * 4.2: Contractor

4.3: Start Date * 4.4: End Date *

5: WICRA *

5.1: W Type *

5.1.1: Type A: Inspection and Non-Invasive Activities Includes, but is not limited to: Adjustment and inspection of plumbing systems which do not interrupt water service.

Infection Control Risk Assessment (ICRA) 4Continued on the next page.

5.1.2: Type B: Small scale, short duration activities which create minor water service interruptions.Includes, but is not limited to:Plumbing work which can be isolated from the overall water distribution systemWork which can be completed in a 48 hour period or less

5.1.3: Type C: Work that creates a major water service interruption or requires demolition or removal of any fixed building components or assemblies. Includes, but is not limited to:Major plumbing modifications that result in water service interruption at 4 or more fixtures or multiple roomsWork which creates a water service interruption for more than 48 hoursWork which results in unoccupied units for up to 7 days after water service has been restored

5.1.4: Type D: Major demolition and construction projectsIncludes, but is not limited to:Requires heavy demolition or replacement of water distribution piping, heating, storage, treatment or associated systemsNew building construction, build out of shell space, major renovationsWork which creates a water service interruption for more than 7 consecutive daysWork which results in unoccupied units for more than 10 days after water service has been restored 5.2: W Patient Risk *

5.3: W Class *

5.3.1: Class I During Construction: Execute work by methods to minimize disturbing plumbing system from construction operations.

5.3.1.1: Class I Upon Completion of Construction: Flush hot and cold water from each affected fixture for 1 minute.Clean work area upon completion of tasks.

5.3.2: Class IIDuring Construction:Isolate water system where work is being performed.Post notices prohibiting the use of water from fixtures impacted by the work.

5.3.2.1: Class IIUpon Completion of Construction:Flush cold and hot water from each affected fixture for 5 minutes.Remove notices prohibiting use of water.Clean work area upon completion of tasks.

5.3.3: Class IIIDuring Construction:Isolate water system where work is being performed.Post notices prohibiting the use of water from fixtures impacted by the work.Do not remove notices until approved by Infection Control Department.

5.3.3.1: Class IIIUpon Completion of Construction:Flush hot and cold water from each affected fixture for 5 minutes.Collect water samples for Legionella: a) Less than 10 outlets, 1 sample from each outlet; b) More than 10 outlets, minimum of 10 representative outlets.Remove notices

Infection Control Risk Assessment (ICRA) 5Continued on the next page.

prohibiting use of water.

5.3.4: Class IVDuring Construction:Isolate water system where work is being performed.Post notices prohibiting the use of water from fixtures impacted by the work.Do not remove notices until approved by Infection Control Department.

5.3.4.1: Class IVUpon Completion of Construction:Flush cold and hot water from each affected fixture until no discoloration is observed.Perform a hyper-oxidation (chlorination) treatment and document results.Collect water samples for Legionella: a) Less than 10 outlets, 1 sample from each outlet; b) More than 10 outlets, minimum of 10 representative outletsDo not allow water use until test results are returned and system is safe to open for consumption.Flush each outlet for 1 minute at least 5 days out of every 7 days until test results are returned.Remove notices prohibiting use of water.

5.4: W Time *

5.5: W Valves *

5.6: W Temporary *

* = required field

Infection Control Risk Assessment (ICRA) 6This form was generated by LEAF on 3/28/2024