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Current Trends in Managing
Patient & Staff Health Risks
during Healthcare Construction Projects
Presented by:
John Martinelli
Director, Healthcare Services
March 5, 2015 - CSHRM 2015 Annual Conference
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Session Objectives
Upon completion of this session you will be able to:
• List regulations and guidance documents that call for proactive
Infection Control/Pre-Construction Risk Assessments
(ICRA/PCRA)
• List the elements to be considered when conducting a PCRA
and the key participants that should be included in the multidisciplinary risk assessment team
• List at least two common risk mitigation measures used to
manage risks to the environment of care during construction,
methods commonly used to monitor the effectiveness of those
measures and the benefits and potential limitations of each
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The Joint Commission
Environment of Care Standard Requirements
EC02.06.05
EP 1. When planning for new, altered or renovated spaces the
hospital uses design criteria, state rules and regulations, AIA
Guidelines (2001), other reputable standards or guidelines
EP 2. The hospital conducts preconstruction risk
assessments for air quality, infection control, utility
requirements, noise, vibration and other hazards that
affect care, treatment and services
EP3. The hospital takes action based on its assessment to
minimize risks during demolition, construction or renovation
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Updated PCRA Forms
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Joint Commission 2011
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Joint Commission 2010
FGI 2010 Guidelines
PCRA (ICRA) Team Required
Infection Prevention
Direct Patient Care - clinical, from impacted department(s)
Facility Knowledge – HVAC, MEP
Scope of Project
Other(s) as dictated by scope
PCRA done (started) during planning,
continued through commissioning
Owner or 3rd party conducts monitoring of risk
mitigation measures for the duration
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Multi-Disciplinary Team Approach
• Multiple experts to:
– Help identify risks
– Assign risk mitigation measures
– Determine methods to evaluate effectiveness
• Which of the experts knows about:
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Infection Control?
The buildings MEP systems?
The scope of the project?
Mold?
Noise?
What does Air Quality mean?
How to test, when to test?
How to interpret test data?
Generally no single person knows all of the issues
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Multi-Disciplinary Team Approach
Expert
Infection Prevention
Department Reps (Clinical)
Facility Engineer
Project Manager
GC/CM
Architect
Specialty Trades
EH&S
Industrial Hygienist
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Issue
Air Quality
Infection Control
Noise
Vibration
Utilities
Other hazards
Emergency Preparedness
Documentation
Testing
Communications
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Roles and Responsibilities
• Owner
– Responsible to conduct the PCRA
• Infection Control Professional
(aka Infection Prevention)
– EC 02.06.05 Infection Control
– Identifies (or confirms) the risk group(s)
impacted by the project
– Typically a clinical professional, on hospital staff,
may be a manager
– May be the required signatory for the permit
– Varying degrees of construction project expertise
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Roles and Responsibilities
• Environmental Health and Safety Professional
– EC 02.06.05, Air Quality, Other hazards, perhaps IC
– Review the PCRA, procedures and monitoring methods
– May understand containment, engineering controls,
work practices, etc.
– May be knowledgeable on testing methods and
interpretation of data
– Often participates in Environmental Tours
– May be aware of other hazards (chemicals, biologicals)
– May provide information on in-house policies,
documentation requirements
– May be tasked with assigning risk groups
– May have access to asbestos inspection reports
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Roles and Responsibilities
• Facility Manager/Building Engineer
– EC 02.06.05, Utilities;
LS01.02.01, Life Safety Systems
– Excellent source for utilities related issues
– Can provide information on HVAC system,
medical gas line locations, confined spaces, above ceiling access
requirements, water features, shut offs, etc.
– Can help determine where vibration impact will travel
– May provide input on in-house policies for HVAC and plumbing recommissioning (testing, flushing, treatment)
– Sometimes knows the scope of work
– May also have access to asbestos inspection reports
– Often difficult to get to a meeting
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Roles and Responsibilities
• Construction Project Manager
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EC02.06.05 all elements; LS01.02.01
Knows the scope and phasing
May know the methods of the subcontractors
May understand the EC requirements
May understand testing methods and data
interpretation
– May have contractual requirements to implement
(and monitor) risk mitigation measures
– May have forms that can be used to document
conditions or findings (meeting minutes, logs)
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Roles and Responsibilities
• Architects/Design Engineers
– EC02.06.05 all elements; LS01.02.01
– Know the scope and phasing
• Water systems, HVAC shut downs or tie-ins
– May have knowledge of impacted departments
well in advance
– May provide advance warning for impact on
utilities, need for above ceiling inspections
– May include testing in specifications without
clear understanding of impact (cost, timing, data
interpretation/acceptance criteria)
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Roles and Responsibilities
• Subcontractors
– EC02.06.05 Noise, Vibration, AQ
– Install containment and engineering
controls
– Will know chemicals and methods to be
used (noise and vibration issues)
– Schedule and duration
• 3 people, 3 days or 4 people, 2 long shifts, etc.
– Need to know where to exhaust, how to
enter and exit the work area
• Sometimes the first time the superintendant
sees the work plan is the day s/he arrives on
the job
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Roles and Responsibilities
• Medical Staff/Clinicians
– EC02.06.05 Infection Control, Noise
– Assign risk groups, provide important input on
the impact of noise, vibration or patient
relocation
– Department Managers have department specific
information
• AIIR’s, hand washing locations, schedules for
procedures)
– Can provide information, support and education
on infection risks based on department/history
– May have input on analytical/lab methods
• Desired data, level of analyses, air, surface, water
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Roles and Responsibilities
• Environmental Services (EVS)
– EC02.06.05 IC, other
– Most likely will conduct pre-occupancy
(terminal) cleaning and need to know
where work impacted the environment
– Can provide information on preferred
(or prohibited) cleaning agents
– Know where sharps and biohazard
waste containers are located and
should be the ones removing them
prior to construction
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Roles and Responsibilities
• Industrial Hygienists
– EC02.06.05 all elements; LS01.02.01
– Understand construction, building functions,
regulatory requirements, environmental
sampling.
– Provide expert level consultation on
applicability, benefits and limitations of testing
methods and data interpretation.
– Can provide third support for the owner and
avoid conflict of interest issues
– Can provide independent communication
support
• Town hall meetings, PIO
– Help build confidence between the
construction side and the clinical side
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Noise Risks
Volume may not be the only
noise-related issue
Beyond just volume risks can
include:
Interference with ability to hear people or devices
• Power tools or other construction and/or demolition activities may
generate sounds similar to audible alarms
• Some people just talk softly
Agitation of patients, family members
Evaluate impact to patients and staff
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Risks and Mitigation Measures
Noise and Vibration
• Who can identify the sources of noise and
vibration?
- Project Manager, General Contractor,
Subcontractors, others?
• Who can identify the noise risks to the
environment and/or patients?
- Clinical staff, Biomedical Engineering, others?
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Risks and Mitigation Measures
AIR QUALITY/INFECTION CONTROL
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Risks and Mitigation Measures
Air Quality
• Who will evaluate the impact on the Environment?
– Clinical staff
• Procedure schedules, path of travel, special requirements
(gowning, hand hygiene)
• Patient risk groups
– Plant Ops
• Air balances, HVAC component and locations, Med gas, steam
– Subcontractors
• Locations of containment, controls and exhaust locations
– EH&S, Industrial Hygienists
• Testing methods
• Environmental Monitoring, Data interpretation
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Benefits of the
Multi-Disciplinary Team Approach
• Meets the recommendations set forth in CDC and
AIA/FGI Guidelines (referenced by EC standard)
• Includes multiple experts to ensure risks are
adequately considered and appropriately managed
• Builds confidence in the team
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Helps avoid complaints from impacted departments
Helps avoid clinical disruptions
Helps avoid project disruptions
Minimize impact on the Environment of Care
Prevents HAIs related to construction projects
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Case Study 1 – OR Suite Flooring Replacement
Risk – Dust (Aspergillus)
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Case Study 1- Project Goals
• Phased removal of flooring and some walls
in ORs while others remain functional
• Control impact of dust, noise and vibrations
during project activities
• Maintain critical air balances for the duration
of the project
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Identifying and Managing Risk
• Temporary/localized pressure changes impact
sensitive design requirements
– Engineering?
• Poorly controlled dust from activities has
adverse impact on patient safety and operations
– Infection Prevention, EVS, EH&S, Hygienist
• Perceptions and communications
– Who will be impacted
– Who will communicate, when and how
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Considerations
• What engineering controls, where, and when
• Phases?, Exhaust locations?, Ante rooms?
• Pressure differentials, air changes, path of travel
• Establish monitoring methods, criteria,
documentation, and communications
• Testing schedules
• Include indoor control locations when possible
• Team in agreement prior to mobilization
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Case Study 1- Events and Actions
• Code Blue announced via overhead paging
system (12:45am), Project already in demo
phase
• Pressure differential and particle counting
data collected immediately after hearing the
announcement
• Data analysis showed acceptable criteria at
all data points
• Construction crew notified of code call
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Patient Transported passed Work Area Entrance
(~1:20am)
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Patient in Room
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Case Study 1 - Events and Actions
• Pressure differential and particle counting
data collected immediately after patient is
taken passed the work area
• Data collected again at patient OR threshold
after patient was in the room
• Data analysis showed acceptable criteria at
all data points
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Case Study 1 Results
• Particle data showed hall outside contained work area
had lower particle counts than indoor control locations
and other hall locations in the suite
• Particle data showed path to, hall outside OR with
patient remained in baseline ranges
• Pressure differential data confirmed that work area
containment was under negative pressure
• Pressure differential data confirmed that OR where
patient was treated remained under positive pressure in
relation to the adjacent hall
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Case Study 1 Summary
• Instruments and observations helped document that
controls were effective but without data…
– Do we have proof?, Are we defensible?
• Data collection offered real time analysis of indoor
conditions (real time data is not always attainable)
• Events and data reported to Department Manager next
morning (via email attachments)
• Construction team congratulated for a job well done
• Confidence built between construction and clinical teams
• Data in hand to prove effectiveness of controls
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Case Study 2 – 4-phase Sterilizer Replacement
Project
Risk – Dust, Maintaining Pressures
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Special Work Practices and Controls
(SPD Mgr, Contractor, Engineering)
• Install barriers (Locations and timing)
– Gowned whenever passing through clean side spaces
• Establish negative pressure
– Bridged Clean and Decon Sides
• 2 zones become 3; HVAC registers impacted (Engineering)
– Onsite validation (EH&S / IH)
• Conduct work in controlled environment
– Put on new clean gowns prior to walking back into
clean side
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Other Work Practices
• Clean work area after work is completed
– Damp wipe and HEPA vacuum
– No cleaning chemicals planned for contractor
cleaning (EVS / SPD Mgr)
• Phased barrier removal (Contractor / EH&S / IH)
• EVS terminal Cleaning (EVS / SPD Mgr)
• Significant coordination, timing and
communication demands (full team)
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Exhausting to an Adjacent Space
• The plan pulled air from the work area and
exhaust the highly filtered air into the wrap
and pack side.
– Allows to maintain negative pressure in the
work area, ensure positive pressure in clean
side
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Containment and Negative Pressure
Phase 1
Decon side containment
Wrap and Pack side
containment
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Containment and Negative Pressure
Phase 1
Decon Chamber/
Ante Room
HEPA Filtered Neg Air Machines
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Decon Chamber/
Ante Room
Phase 2
HEPA Filtered Neg Air Machines
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Phase 3
Decon Chamber/
Ante Room
HEPA Filtered Neg Air Machines
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Phase 4
Decon Chamber/
Ante Room
HEPA Filtered Neg Air Machines
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Final Details
• Approved Path of Travel
• HVAC supply and return registers inside work
areas
– Proposed to be protected with filters (not sealed)
• Phone tree for emergencies
• Decon entry/exit locations
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Case Study 2 Summary
• Baseline testing indentified problems with air balances
before the project started
• Conditions during and after project were better than
before
• Work flow and process modifications minimized
production losses
• Department staff learned impact of propping open doors
• Improved confidence and communication between
Construction Team, Infection Prevention and Clinical
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Two Examples of Team Driven Success
But…
“My time is
valuable”
$$$
Someone needs to lead/manage the team
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Recap
• Regulations require Risk Assessment
– Joint Commission EOC Standard 02.06.05
• Multi-disciplinary Team Approach
– Best Practice, Effective
• Tools available to Guide the Team
• Common Mitigation Measures include
– Containment with Negative Pressure
– Controlled traffic patterns
QUESTIONS?
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Thank You
John Martinelli
[email protected]
Forensic Analytical Consulting Services, Inc.
Right People, Right Perspective, Right Now
www.forensicanalytical.com
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