ATTACHMENT B_Infection Control Risk Assessments for Work Orders.pdf

Facility Management FMD-058 VAMC, Milwaukee, Wisconsin January 2020

Infection Control Risk Assessments (ICRA) for Work Orders

1. PURPOSE: The purpose of this Policy is to specify the control of environmental infection control and risk assessment which Milwaukee VAMC Facility Management staff must follow for work orders at the Medical Center.

2. SCOPE: This procedure applies to all Milwaukee VA Medical Center work orders except for those exempt as described in Appendix A

3. BACKGROUND: Certain activities in specific areas from work orders present an infection control risk. The below procedure provides an infection control risk assessment by incorporating area representatives and Infection Control Coordinators when applicable.

4. RESPONSIBILITIES:

a. PM&R, Utilities, Architectural and Paint Shop staff shall be responsible for “Work Order Risk Assessment for Infection Control Card” when assigned a work order from their supervisor. In addition, they are responsible for determining and incorporating the Infection Control Precautions as described in Step 4 below.

b. PM&R, Utilities, Architectural and Paint Shop Supervisors or Work Leaders shall be responsible for assigning work orders to staff and assuring the assigned staff complete the “Work Order Risk Assessment for Infection Control Card” and incorporate the applicable Infection Control Precautions. In addition, they are responsible collecting the completed “Work Order Risk Assessment for Infection Control Card” and maintaining the cards as described in #6 below.

c. The Infection Control Coordinator shall provide infection control advice.

d. Area Representatives shall provide input for Class III and IV maintenance activities concerning the potential concerns and exposures. Area Representatives include the affected area’s supervisors, work leaders, or charge nurses.

e. Maintenance and Operation Superintendent shall oversee the Work Order Infection Control Risk Assessment process to ensure compliance with this Policy including intermittent audits to verify policy compliance.

5. PROCEDURES:

a. STEP 1: Review of Work Orders

1) Upon receiving a work order assigned from their supervisor (or Work Leader), Shop staff reviews incoming work orders and completes the “Work Order Risk Assessment for Infection Control Card.” (Attachment B)

Note: If the work order involves the Exemption List (Attachment A), then the Shops staff need not go further with this IC Risk Assessment.

2) If checked “Yes” on the checklist, the supervisor shall proceed with Step 2.0 below. If all responses are “No”, then no further action is required

b. STEP 2: Determining the Infection Control Precaution Level (I, II, III, IV)

1) Location – A color coded floor plan for the Medical Center has been developed with Patient Risk Groups (Low, Medium, High and Highest).

Low Risk Medium Risk High Risk Highest Risk

Office areas

Cardiology

Echocardiography

Endoscopy

Nuclear Medicine

Physical Therapy

Radiology/MRI

Respiratory Therapy

Ambulatory Care Clinics

Emergency Room

Laboratories (specimen)

Outpatient Surgery

Pharmacy

Post Anesthesia Care Unit

Surgical Units

Linen

Kitchen & Canteen

Any area caring for immune-compromised patients

Burn Unit

Cardiac Cath Lab

Central Sterile Supply

Intensive Care Units

Medical Unit

Negative pressure isolation rooms

Oncology/Radiation Therapy

Operating rooms

Dialysis

2) Type of Work. – Maintenance Activities may be classified by the below:

TYPE A

Activity will not generate visible dust and is less than 15 minutes in length

Inspection and Non-Invasive Activities.

Includes, but is not limited to:

• removal of ceiling tiles for visual inspection limited to 1 tile per 50 sq.

feet

• painting (but not sanding)

• wall covering, electrical trim work, minor plumbing, and activities not generating dust or require cutting of walls or access to ceilings other than for visual inspection.

• Removal of floor tile less than 25 square feet, non-ACM and no grinding or dust generating activities

TYPE B

Dust generation activity is less than 1 hour

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

Dust generation activity is exceeds 1 hour but less than one day.

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 maintenance or renovations over 3 days duration

• major duct work, plumbing, piping, or electrical work

• soldering or brazing operations

• ANY activity that requires a burn permit

TYPE D

Dust generation activity exceeds one day.

Major demolition and maintenance projects

Includes, but is not limited to:

• activities which require consecutive work shifts

• requires heavy demolition or removal of a complete building system

• new maintenance or renovations over 3 days duration

c. STEP 3: Identify Level of Infection Control Precautions Required

Match the Patient Risk Group with Maintenance Activity Type on the following matrix to find the level of infection control precautions required.

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

Infection Control approval will be required when the Maintenance Activity and Risk Level indicate that Class III or Class IV control procedures are necessary.

IC Matrix - IC Maintenance Activities Classification

Maintenance Activity Type

Patient Risk Group TYPE A TYPE B TYPE C TYPE D

LOW Risk Group I II II III/IV

MEDIUM Risk Group I II III IV

HIGH Risk Group I II III/IV IV

HIGHEST Risk

Group

II III/IV III/IV IV

d. STEP 4: Description of IC Precautions by Class Level

During Maintenance Activity Upon Completion of Maintenance

C L

A S

S I

A. Execute work by methods to minimize raising dust from maintenance operations.

B. Immediately replace a ceiling tile displaced for visual inspection

A S

S I I

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

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

4. Utilize “shark tank” and/or seal unused doors with duct tape.

5. Utilize “shark tank” and/or block off and seal air vents.

6. Place dust mat at entrance and exit of work area.

1. Wipe work surfaces with disinfectant.

2. Contain maintenance waste before transport in tightly covered containers.

3. Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area.

4. Remove isolation of HVAC system in areas where work is being performed.

C L

A S

S I

II

1. Remove or isolate HVAC system in area where work is being done to prevent contamination of duct system.

2. Utilize “shark tank” and/or complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non-work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before maintenance begins.

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

4. Contain maintenance waste before transport in tightly covered containers.

5. Cover transport receptacles or carts. Tape covering unless solid lid.

* Use window for negative HEPA air exhaust when accessible. Obtain V.A, resident engineer approval for exhausting in existing exhaust ductwork.

1. Do not remove “shark tank” or barriers from work area until completed project is inspected by the owner’s Safety Department and Infection Control Department and thoroughly cleaned by the owner’s Environmental Services Department.

2. Remove “shark tank” and barrier materials carefully to minimize spreading of dirt and debris associated with maintenance.

3. Vacuum work area with HEPA filtered vacuums.

4. Wet mop area with disinfectant.

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

A S

S I V

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

2. Utilize “shark tank” and/or complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non-work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before maintenance begins.

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

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

5. 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.

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

7. Do not remove “shark tank” or barriers from work area until completed project is inspected by the owner’s Safety Department and Infection Control Department and thoroughly cleaned by the owner’s Environmental Services Department.

1. Remove “shark tank” and/or barrier material carefully to minimize spreading of dirt and debris associated with maintenance.

2. Contain maintenance waste before transport in tightly covered containers.

3. Cover transport receptacles or carts. Tape covering unless solid lid

4. Vacuum work area with HEPA filtered vacuums.

5. Wet mop area with disinfectant.

6. Remove isolation of HVAC system in areas where work is being performed.

6. DOCUMENTATION AND RECORD KEEPING:

Facilities Management shall document all Class III and Class IV Infection Control Risk Assessment maintenance activities on the fmdcom drive, Work Order folder, “ICRA for WOs Class III and IV”. Work Order Risk Assessment for Infection Control Cards” shall be retained by the FM Service Officer for thirty-six (36) months for review and auditing purposes.

7. Approval

LINDA SUE SCHWARZ, P.E., CHFM, LEED-AP

Division Manager, Facility Management

DISTRIBUTION: O & M Supervisors, O&M Work Leaders, FM Program Managers, Design and Development; PM&R; Utilities; P&E; Architectural and Support Attachments (2)

ATTACHMENT A

Engineering Work Orders Not Requiring an Infection Control Permit or Review

(Exempt for the Work Order Infection Control Risk Assessment)

• Painting and/or wallpapering in administrative offices and non-patient care areas.

• Painting in patient care area if the area is closed for the painting and less than 3

sq. ft. of wall needs patched.

• Installation of soap dispenser/sharps collection box/paper towel dispenser

• Window blind repair

• Ceiling tile replacement in non-patient care areas and the replacement is less than 50% of total square footage of the room and if the area does not open up to a patient care area.

• In a patient care area if the ceiling tile replacement is one ceiling at a time and less than five (5) 2’ x 4’ tiles, the patient is not occupying the room, the room can be contained (door closed) and clean up can be achieved before patient returns.

• Minimum repair of nurse call system/TV/bed or telephone without ceiling/wall penetration.

• Replacement of light bulbs

• Removal of a sink or commode clog

• Repair of medical gas outlet (front body)

• Conducting air balance readings

• Assessing the heat or air conditioning in the area.

• Furniture Moves

• Core key replacements not requiring drilling of material

• Simple door closure adjustments (not requiring drilling, welding, soldering or brazing).

ATTACHMENT B

Work Order Risk Assessment for Infection Control Card Work Order #:__________

1. Is the work involved listed on the ICRA Work Order Exemption list:

Yes____ No_____

If checked “Yes” above, then nothing further

2. Location of Maintenance Work Order:

a) Patient Occupied Areas: Yes____ No _____

b) HIGH RISK AREAS: Burn Unit, Cardiac Cath Lab, SPS, ICUs, negative isolation rooms, Oncology/Radiation Therapy , Operating Rooms, Dialysis and any areas with immune-compromised patients.

Yes_____ No _____

3. Type of Maintenance Activity:

a) Type A: Activity will not generate visible dust and is less than 15 minutes in length:

Yes_____ No_____

b) Type B: Dust generation activity is less than 1 hour Yes_____ No_____

c) Type C: Dust generation activity is longer than 1 hour but a single day activity

Yes_____ No_____

d) Type D: Dust generation activity exceeds 1 day Yes_____ No_____

If checked “Yes” for 2 or 3 above then appropriate Infection Control measures must be implemented (SEE

BACK OF CARD)

ATTACHMENT B

Appropriate Infection Control (IC) Measures:

• If HIGH RISK Area and/or Type C or D Maintenance Activity, utilize the Infection Control

Precautions for Class III or Class IV whichever is applicable as described by Procedures listed in within Infection Control Risk Assessment for Work Orders Policy, FMD-057.

• If Type A in a Patient Occupied Area, utilize the Infection Control Precautions for Class I. If

Type B Maintenance Activity located in a Patient Occupied Area, utilize the Infection Control

Precautions for Class II or Class III whichever is applicable as described by Procedures listed in within Infection Control Risk Assessment for Work Orders Policy, FMD-057.

• If Type A or B Maintenance Activity and located in non-patient area, contact the Area

Representative, otherwise no further action is needed.