ICRA_Template_doc.pdf

USNHNAPINST 6220.1 Series

USNHNAP 5100/12 (10-2015) Page 1 of 3

Pre-Construction Risk Assessment: Infection Control & Safety Location of Construction Project Start Date:

USNH Staff POC/Telephone: Estimated Duration:

Contractor Performing Work: Permit Expiration Date:

Supervisor: Telephone:

Description of project:

Construction Activities: The following projects DO NOT require completion of this form:

1. Paint in offices and non-patient areas OR paint in patient room if closed for painting and less than 10sf of wall needs patched (change filter for room unit after work)

2. Ceiling tile replacement for less than 10 (2x2) tiles, if in business offices and non-patient areas; ceiling tile replacement for less than 5 (2x2) tiles in a patient area if closed for work and cleaned after

3. Routine maintenance on doors, windows, sinks and lights

4. Minimum repair of nurse call system, TV, telephone, medical gas outlet, window or window blind, or installation of soap dispenser/needle box/paper towel holder in patient room

5. Check or replace electric outlet, replace light bulb

6. Unstop sink/commode w/ no water on floor OR unstop commode w/ water on floor but janitorial cleans area immediately

7. Air balance readings, check air-conditioning

Fill out questionnaire to determine Type:

Type A Inspections and non-invasive activities or small scale, short duration activities Yes No

Removal of ceiling tiles for visual inspection (limited to 1 tile per 50 square feet) Painting (but not heavy sanding) Wall covering—Describe work to be done:

Electrical trim work. Describe:

Minor plumbing. Describe:

Type B Small scale, short duration activities that create minimal dust Yes No Installation of telephone and computer cabling in overhead Access to chase spaces Sanding of walls for painting or wall covering (minor repairs—not sanding for drywall finishing)

Type C Any work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies. Location of and plan for interim dust barriers must be clear. (May require approval from Fire Inspector)Yes No Extensive Sanding of walls--drywall finishing Removal of floor coverings ceiling tiles casework Describe:

Cutting of walls or ceiling. Describe:

New wall construction Minor ductwork or electrical work above ceilings. Describe:

Major cabling activities Activity cannot be completed within a single work shift Has approval been obtained from Fire Inspector?

Type D Major demolition and construction projects. (Fire Inspector approval required)Yes No Will require heavy demolition or removal of a complete ceiling system New construction or major remodeling.

Has approval been obtained from local Fire Inspector?

Circle which Group applies:

GROUP I

LOWEST

GROUP 2

MEDIUM

GROUP 3

HIGH

GROUP 4

HIGHEST

1) Office areas

2) Areas not used for patient care, holding or transport

3) Health Prom. Kitchen

1) Lobbies/Reception

2) Physical Therapy

3) Admission/Discharge

4) All Outpatient Clinics, EDIS

5) Clinical Laboratories

1) Emergency Room

2) Radiology

3) Post-anesthesia Care

4) MSW & Labor and Delivery

5) Maternal Newborn

1) Operating Rooms (incl L&D)

2) Anesthesia Areas

3) Endoscopy & Minor Surgery

4) Pharmacy Compounding room

5) CSR (Clean Side)

Based on Type and Group identified above, circle which Class of Work applies:

Infection Control Group

Type A Routine inspection, testing and non-invasive activity

Type B Small scale, short duration projects usually <4 hours

Type C May generate moderate to high levels of dust or duration of >8 hours

Type D Major construction, renovation or demolition requiring several days to complete 1 Lowest I I II III/V

2 Medium I II III IV

3 High II III III/IV IV 4 Highest* II III/IV III/IV IV

**If work will be done in a sterile area, must describe in Comments how the sterile atmosphere will be maintained**

USNHNAP 5100/12 (10-2015) Page 2 of 3

Based on pg1 results, circle applicable requirements:

CLASS

I

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

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

CLASS

II

1. Provide 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 and during 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 as needed.

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

CLASS

III

1. Obtain infection control permit before work begins.

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

3. Complete all critical barriers before construction begins.

4. Maintain negative air pressure within work site utilizing

HEPA equipped air filtration units.

5. Contain construction waste before and during transport in tightly covered containers.

6. Seal holes, pipes, conduits, etc. appropriately.

7. Place dust mat at entrance and exit of work area. Replace as needed.

8. Do not remove barriers from work area until completed project is inspected by Safety and Infection Control and thoroughly cleaned.

After work is completed:

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

10. Remove isolation of HVAC system.

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. Contain construction waste before and during transport in tightly covered containers. Cover transport receptacles or carts. Tape covering.

9. Do not remove barriers from work area until completed project is inspected by Safety and Epidemiology Depts. and thoroughly cleaned.

After work is completed:

10. Vacuum work area with HEPA filtered vacuums.

11. Wet mop with disinfectant.

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

13. Remove isolation of HVAC system.

Fill out questionnaire for additional precaution requirements:

Environmental Impacts Yes No

Will hazardous chemicals be used on this project? Explain in comments how vapors will be controlled. MSDS Sheets are required.

Will there be hot work done on this project? If so, a hot work permit is required and must be posted on the job site.

Will there be a confined space entry required on this project? If so, the NSA confined space entry program must be followed.

Will there be noise generated that will impact a department adjacent to, above, or below the construction area? If so, these departments must be notified and describe in Comments how are you going to reduce the noise to an acceptable level Will there be vibration generated that will impact a department adjacent to, above, or below the construction area? If so, these departments must be notified and describe in Comments how are you going to reduce the vibration to an acceptable level

Utility Impacts Yes No Will any of the following systems be out of service at any time during the project? Describe mitigation actions in Comments.

Fire alarm (If > 25% out for more than 4 hours, ILSMs must be implemented.)

Sprinkler (If > 25% out for more than 4 hours, ILSMs must be implemented.)

Electrical Domestic water Oxygen Sewage

HVAC

Fire/Life Safety Impacts Yes No

Will work that will require activation of Interim Life Safety Measures during this project? Activities such as, but not limited to:

Any construction that impacts an EXIT or stairs **must provide plan of notification/alternate routing** Any construction that impacts or creates major breaches in a fire or smoke wall, Taking the main fire protection system (sprinkler) out of service for an entire area, Taking the main fire alarm system out of service for an entire area, Taking the “area” fire protection or fire alarm systems out of service for more than 4 hours within a 24-hour period.

If marked “Yes”, ILSM form must be completed. See Safety Department.

Will the work require the following Safety precautions?

Separation wall constructed prior to start Extra fire extinguishers in work areas Extra exit lights in work area Daily logs Current Hot Work Permit

USNHNAP 5100/12 (10-2015) Page 3 of 3

REQUIREMENTS FOR ALL CLASSES:

1. Put signs on doors into construction area “Construction Area – Do Not Enter” and redirect traffic not to go through construction area.

2. Maintain a very clean and orderly jobsite – at the end of each day and during work if necessary, clean fine dust from floors and adjacent occupied areas with dust mops, wet mops, brooms, buckets, and clean wiping rags.

3. Contain work areas, including spaces above ceilings if needed, with full height polyethylene sheet barrier, tightly taped. Temporary construction barriers and closures above ceiling must be dust tight.

4. Maintain negative air in construction area (24/7) through duration of project. Supply ducts to the area must be closed and HEPA filtration unit in place and functioning in adjacent patient care area OR ducts need to have filters mounted. There cannot be any return air from within the construction area to the rest of the building.

5. Place sticky mats at doors exiting construction area. Clean up dust tracked outside of construction area immediately.

6. Removal of debris must be in covered containers: must explain plan for removal and control in Comments.

7. Emergency Procedures discussed and posted if necessary at job site.

8. Fire protection systems must remain intact.

COMMENTS:

APPROVAL:

USNH Staff POC Review Safety Approval Infection Control Approval

Printed name Printed name Printed name

Signature Signature Signature

Date Date Date