Download Hospital Construction and Infection Control

Hospital Construction and
Infection Control
Larry Lee, CIH
September 23, 2009
Pacific Industrial Hygiene LLC
5520 106th Ave NE, Kirkland, WA
[email protected]
425-269-1488
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Introduction
Larry Lee, CIH
• Certified Industrial
Hygienist
• Indoor air quality
• Hospital Flood ’96
• Specialize in
healthcare
construction &
infection control
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Presentation objectives
• Identify patient risks of infection associated with
healthcare construction
• Identify important infectious agents
• Recognize control measures used to prevent
infection from construction
• Understand the role Environmental Services
plays in infection prevention
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Hospital Construction and
Infection Control
What’s the big deal?
• The problem
– Construction activity is a risk
factor for life-threatening fungal
infections in immune
compromised patients.
• The cause
– Construction in occupied
buildings turns normal building
functions on its head
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Fungal infections
Fungi and mold
• Ubiquitous in the environment
– Soil
– Air
– Water
• Need food – carbon – to grow
• Break down organic material in
environment
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Opportunistic infection
Requires exposure
– Mold species are ubiquitous
– All humans are exposed to fungi as a consequence of
living on earth
Requires susceptible host
– Hyper-responsive (allergy)
– Defective defenses
• Underlying illness/condition
• Barrier defects
• Cellular & acquired immune deficiencies
Requires fungal growth at body temperature (37⁰ C)
Aspergillus and other species
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Opportunistic Aspergillus species
• Aspergillus fumigatus (~90% invasive
illness worldwide)
• A. flavus
• A. niger
• A. terreus
• A. nidulans
• A. ustus
• A. lentulus
•
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Courtesy Aspergillus website
Aspergillosis – spectrum of disease
Allergic disease
• Asthma, ABPA &
allergic sinusitis
Colonization
• Fungal balls
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Semi-invasive disease
• Fungal ball & invasion
• Fibrosis & cavitary
Invasive disease
• Sinus
• Pulmonary
• Disseminated
Aspergillosis
Invasive disease characteristics
– Opportunistic infection
– Mortality
• ~30% to >90% depending on patient population
– Illness is difficult to treat
– Treatment is difficult on the body
• Amphoterin B – “Ampho-terrible”
• Drug resistance emerging
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Patient risk factors
Compromised body defenses
Barriers
• Skin
– Burns
– Surgery (implantation)
• Mucosa
– Sinus
– Gastrointestinal tract
– Bronchopulmonary tract
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Patient risk factors
Immune response
• Cellular
– Macrophages
– Neutrophils
– Dendritic cells
• Adaptive – coding, recognition, regulation
& deregulation
– T cells
– CD+4
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Cellular response
Macrophages
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Neutrophils
At-risk patients
Deficient defenses increase risk of infection
• At-risk population is defined according to:
– Illness
– Therapy
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
At-risk patient populations
Transplantation
Oncology
• Bone marrow
• Hematopoietic stem cells
• Leukemia
• Chemotherapy &
radiation
• Corticosteriod treatment
– Allogeneic
– Autologus
• Solid organ
–
–
–
–
Lungs
Heart
Liver
Kidney
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Burns
Cystic fibrosis
COPD
At-risk patient populations
• Diabetes mellitus
(unregulated)
– Dialysis
• Cavitary illness (dead
lung tissue)
– Tuberculosis
– Late stage HIV/ AIDS
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
• Chronic granulomatus
disease
• Premature infants
• Severe malnutrition &
alcoholism
• Surgical patients
Construction & Aspergillosis
• Fatal outbreaks of
aspergillosis have been
associated with
construction worldwide
• Construction disrupts
air flow patterns and
disturbs dust and mold
spores that can be
harmful to at-risk
patients
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Construction activities
Exterior construction
• New and existing buildings
– Ground breaking
– Earth & tree work
– Utilities installation
– Demolition
– Re-roofing & cladding
– Paving/road work
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Construction activities
Interior construction
• New and existing buildings
– Tenant improvement
– Floor & carpet repair
– Relocation
– Building connection
– HVAC system & utilities upgrade
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Construction activities
Interior construction
•
•
•
•
•
•
•
Window replacement
IT/IS – cable pulling
Phone & fiber optic cable installation
Equipment/lab hood installation
Inspections
Water damage response &repair
Mold, asbestos & lead abatement
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Healthcare construction
• Hospitals and healthcare
– All construction – all the time
• Construction
– Disturbs settled dusts
– Disrupts air patterns
– Disrupts normal vehicle and foot traffic
– Disrupts the normal routine
– Increases the risk of exposure
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Healthcare construction
Mold spore concentrations can increase
during construction
– Infiltration of unfiltered air
– Track-in
– Disturbance of dust reservoirs
• Carpet & ceiling tiles
– Water damage and mold growth/discovery
– Air pathway changes
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Air pathways
Buildings
“breathe”
• Chimney effect
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Air pathways
Elevators
• Piston effect
• Drives local air movement
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Managing construction
• Infection Control Risk Assessment
– ICRA
– Joint Commission requirement
• Matrix
– Evaluates patient population and room use
– Evaluates dust disturbing construction
activities
– Determines type & extent of controls
• Increased risk & disturbance increases
level of control
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Controls
• Barriers and enclosures
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Controls
• Barriers
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Controls
Isolate & protect HVAC system
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Controls
Depressurize work area
– HEPA filtered negative air
machines
– Exhaust outdoors preferred
– Exhaust indoors
• Pre-clean discharge area (HEPAvacuum)
• Secure ceiling tiles (prevent
vibration)
• Minimize discharge flow rate
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Controls
Tacky walk-off mats
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Environmental services
Role
– Supports cleaning outside work area
perimeter
– Responds to dust/dirt events
– Performs terminal cleaning at return of work
area from contractor
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Environmental services
Tool box
• Cleaning compounds
– Fungicidal & used per label
instructions
– Dilute bleach (1-5%)
– Quat/alcohol blends
• Alcohol may not be listed on
MSDS (<1%)
– Copper-8 quinolinolate blends
– Hydrogen peroxide
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Environmental services
Tool box
• HEPA-filtered vacuum cleaners
• Microfiber cloths
Procedures & protocols
• Tailor to patient population & use
– OR & BMT Unit v. Admin office & lobby
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Environmental services
Terminal/transplant level cleaning
• Top down
– Ceiling, walls, floor
• Take care with ceiling tile
– Keep grid intact to prevent dust storm
– “Non-surfaced” ceiling tile can degrade
• Contact all room surfaces
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Environmental services
The never ending challenge
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Environmental services
Environmental services
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Objectives met
• Identify patient risks of infection associated with
healthcare construction – Opportunistic fungal infections
• Identify important infectious agents – Aspergillus and
other fungal species
• Recognize control measures used to prevent infection
from construction – Barriers/enclosures, negative air
machines, HEPA-filtration and vacuum cleaners
• Understand the role Environmental Services plays in
infection prevention – Perimeter cleaning, dust/dirt
response, and terminal cleaning
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Healthcare construction
• Construction paradox
– Construction is associated with increased risk
of nosocomial aspergillosis outbreaks
– Aspergillosis infection rates were reduced
during major construction at the UWMC
• Construction is an opportunity to improve
infection prevention performance for the
contractor, facilities/engineering, and
environmental services that enhances
patient safety
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV
Thank you
Your questions please
2009 ASHES Annual Conference
September 20-24, 2009
Reno, NV