INFECTION C R ASSESSMENT (ICRA) AWARENESS · 2019-03-29 · CPWR developed this eight hour Infection Control Risk Assessment (ICRA) Awareness program to assist North America’s Building

INFECTION CONTROL RISK ASSESSMENT

(ICRA) AWARENESS

PARTICIPANT MANUALVersion II, September 2016

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8484 Georgia Avenue, Suite 1000Silver Spring, MD 20910

Phone: 301- 578-8500Fax: 301-578-8572E-mail: [email protected]://www.cpwr.comhttp://www.elcosh.org

ICRA AwarenessParticipant ManualVersion 2.0 September 2016

Disclaimer:

© Copyright 2016, CPWR - The Center for Construction Research and Training. All rights reserved. Funding is provided by Cooperative Agreements ES06185 and ES09764 from the National InstitutofEnvironmental Health Sciences (NIEHS), NIH. The contents are solely the responsibility of the authors and do not necessarily represent the offi cial views of NIEHS or NIH.

Acknowledgements:

CPWR would like to thank the following individuals for their contribution to this work:Kelly Dykes; Gary Gustafson; George Newman; Spencer Schwegler

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Introduction

CPWR – The Center for Construction Research and Training conducts research and administers specifi c types of construction health and safety training for members of our consortium partners, and the North American Build Trades Unions. Our overriding goal in all the training we deliver is to enable and empower these construction workers to recognize potentially unsafe working conditions, and to identify proper ways to eliminate or control those hazards that make conditions unsafe.

However, this in no way ever relieves the employers from their primary responsibility of providing workers a safe and healthful workplace.

CPWR developed this eight hour Infection Control Risk Assessment (ICRA) Awareness program to assist North America’s Building Trades Unions in the preperation of their work forces to perform construction, renevation, maintenance and demolition activities on healthcare facilities. Performing work in a healthcare facility requires coordination among all of the construction trades to minimize the risk of spreading infections to hospital patients, staff and visitors. The Center’s main goal is to ensure that members of the Building and Construction Trades understand what it is to work safely and professionally in a healthcare facility.

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The CPWR ICRA Awareness Course has been designed to be clear, direct, and to involve you actively in the learning process.

Learning objectives, found at the beginning of each chapter, tell you what you will be expected to be able to do after you fi nish the training:

• Brief case studies demonstrate the importance of the information and skills taught.• The information that you need is stated in clear, non-technical language wherever

possible. Technical or unfamiliar concepts are carefully explained.• Classroom lectures, demonstrations, and activities help you to be actively involved in

the learning process and to become confi dent in your ability to use what you learn.• Hands-on workshops give you the opportunity to practice putting on, wearing, and

decontaminating protective equipment.• Your instructors are always available to explain any material that is not clear.

It is CPWR’s goal that every trainee leave the ICRA Awareness Course with the basic skills, knowledge and confi dence that he or she needs to work safely on healthcare facilities and that they will be better able to protect themselves on all their jobs. With your active participation, we are confi dent that we will meet that goal.

WARNING

The material was prepared for use by experienced instructors in the training of persons who are or who anticipate working in healthcare facilities. Authors of this material have prepared it for the training of this category of workers as of the date specifi ed on the title page. Users are cautioned that the subject is constantly evolving. Therefore, the material may require additions, deletions, or modifi cations to incorporate the effects of that evolution occurring after the date of this material preparation.

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DISCLAIMER

This program is intended to meet the requirements of providing general training when working in a healthcare, or other occupied, facility. It must be followed by site-specifi c training, during which the specifi cs of the hazards at the site are discussed and practiced. At that time, the elements of the site-specifi c standard operating procedures are given in detail. Additional site-specifi c training for emergency response must be provided so that you understand how to recognize and respond to alarms at the site and can carry out any role which may be assigned during a response.

For information about further training, consult the training instructor, your company safety and health plan, your company health and safety representative, or your union health and safety representative.

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Table of Contents

Introduction 1-1

What is ICRA? 2-1

Differences in Healthcare and Regular Construction 3-1

Hazards Unique to Healthcare Construction 4-1

Hospital Acquired Infections

Developing the ICRA Plan 5-1

ICRA Construction Practices 6-1

Potential Hazards to Workers 7-1

Interim Life Safety Measures 8-1

Posting Signs 9-1

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ICRA Awareness Training

ICRA Awareness:

The ICRA awareness course provides the necessary training to understand the Infection Control Risk Assessment (ICRA) procedures for properly performing healthcare or other occupied facility construction and renovation tasks. In addition, participants will examine the practical use of ICRA tools including containment, negative air, HEPA fi ltration, and work practice techniques. The course uses a variety of adult education classroom activities to build upon the experiences participants have working in construction, renovation, demolition, or healthcare facility environments.

Objectives:

• Defi ne ICRA and explain why it is used.

• Describe how healthcare construction worksites differ from regular construction worksites.

• Explain the importance of following work place rules and using designated areas for breaks, as defi ned by the ICRA.

• Defi ne Hospital Acquired Infections (HAI) and describe the Chain of Infection.

• Identify common pathogens found in a healthcare setting and describe how they are transmitted.

• Identify unique hazards specifi c to healthcare construction, including hospital utility systems and medical gas lines, and methods to avoid them.

• Describe the steps used in the creation of an Infection Control Risk Assessment Plan.

• Specify the specifi c infection control precautions used for the four classes of ICRA construction.

Chapter 4: Monitoring and Sampling

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• Identify different types of barriers used and guidelines for choosing them.

• Describe the procedure for entering/exiting through an anteroom.

• List the two main functions of a negative air machine in an ICRA work environment.

• Describe appropriate methods for transporting trash, tools and materials from the workspace.

• Identify potential hazards to workers in a healthcare setting.

• Defi ne life safety system and explain the use of Interim Life Safety Measures in a healthcare worksite.

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Introduction

Construction work in a healthcare facility such as a hospital, or other occupied facilities such as offi ce buildings and schools may require special procedures, equipment and precautions for performing the work. Construction, renovation and demolition activities can affect hospital patients, visitors and can even cause new infections. Dust from construction, renovation and demolition activities can be a hazard for patients, healthcare workers, and visitors. Dust is especially a risk for patients with compromised immune systems.

To help prevent further injury from construction dust, hospitals use a system called Infection Control Risk Assessment (ICRA) to decide how to protect their patients, staff, and visitors during a construction project. The ICRA will determine the level of barriers, dust control, cleaning, and patient protective apparel you must use during your construction project. You may have to build barriers, maintain negative air pressure inside your work area, or use special air fi ltering equipment. You may have to put up a temporary plastic sheeting barrier while you build a long-term rigid barrier behind it. The ICRA may require you to spend more time putting up barriers to isolate your work area than it takes to actually perform the work.

You need to follow the required infection control precautions while you work, but it is also important for you to understand why those precautions are in place. You have a critical role in protecting the safety of the hospital patients and visitors at your jobsite, and in the surrounding areas.

What is ICRA

ICRA stands for Infection Control Risk Assessment. This practice was developed in the 1990s to help hospital staff prevent infections from spreading within healthcare facilities. Multiple agencies, at state and national levels, require hospitals to use ICRA. Most hospitals are accredited, or approved, by a national organization called The Joint Commission. The Joint Commission evaluates hospitals for patient safety and quality of care, using more than 250 standards. The standards include infection control, and they require hospitals to use ICRA for construction projects. Hospitals have a fi nancial incentive to comply with these standards, because without Joint Commission accreditation, hospitals cannot collect federal government payments for treating Medicare and Medicaid patients.

At the national level, the Center for Medicare and Medicaid Services, a federal government agency, also requires an active ICRA program to avoid sources and transmission of infectious and communicable diseases. Therefore, an organization

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must have a program to conduct and assess risks, implement measures to control, mitigate, or eliminate identifi ed risks, monitor control measures to determine their success and institute modifi ed or new measures to achieve that goal when necessary.

The Centers for Disease Control, also a federal government agency, has issued guidelines for infection control in healthcare facilities. The Centers for Disease Control guidelines include very specifi c procedures for construction, renovation, remediation, repair, and demolition.

Several professional associations have written ICRA guidelines for hospitals to follow. The American Institute of Architects has ICRA guidelines for designing hospital fl oor plans and mechanical systems. The Association for Professionals in Infection Control and Epidemiology has developed ICRA materials for training its members. The American Society for Healthcare Engineering, part of the American Hospital Association, also conducts ICRA training for contractors, construction managers, and hospital managers. The Guidelines for Design and Construction of Health Care Facilities is a comprehensive reference book published by the Facility Guidelines Institute. It includes the use of ICRA for construction and renovation projects. Many state government departments of health now reference the Guidelines in their state regulations for healthcare facilities. By including these Guidelines in their regulations, the states are requiring the use of ICRA.

Local government fi re codes also cover hospitals, and specify fi re resistance standards for construction materials. Hospitals must also follow National Fire Protection Association (NFPA) codes, such as NFPA 101: Life Safety Code, which details requirements for fi re exits, sprinkler systems, alarms, emergency lighting, smoke barriers, etc.

The ICRA principles and methods discussed in this training also apply to construction activities at facilities other than hospitals:

• Medical clinics

• Doctors’ offi ces

• Dentists’ offi ces

• Nursing homes

• Rehabilitation Facilities

• Pharmacies

• Medical laboratories

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• Apartment buildings

• Offi ce buildings

• Schools

• Daycares

The infection control procedures may not be as formal or detailed in other healthcare or occupied facilities as they are in hospitals, but skills from this ICRA training will be useful in those other settings. Air quality control, such as controlling dust, is also a concern for remodeling projects in school buildings, offi ce buildings, restaurants, and manufacturing. People respond differently to dust created by construction. In some sectors of manufacturing, the introduction of dust into the assembly process can shut down production until the entire manufacturing plant is cleaned.

Differences in Healthcare and Regular Construction

Today’s healthcare construction market consists of both new construction and renovation. Healthcare construction involving ICRA typically focuses on renovation or demolition and not new construction. It usually involves the remodeling, upgrading, or expanding of existing buildings. Hospitals might be installing new medical equipment, which may require some demolition, installing new mechanical systems, building new walls, installing new casework, or installing new fi nishes. Older hospitals are doing construction projects to improve the effi ciency of their heating, ventilation, and air conditioning (HVAC) systems, or their mechanical, electrical, plumbing, and fi re protection (MEP/FP) systems. Hospitals are also making technological upgrades, such as installing wireless communications systems and computer terminals for electronic medical record systems. Other hospital remodeling trends include individual temperature controls for patient rooms, and bigger single-patient rooms with private restrooms.

Unlike a typical construction site, hospitals cannot shut down for construction. They have to operate 24 hours a day, seven days a week! On a typical new construction or demolition site, no one is around but

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construction workers. But on a healthcare or other occupied facility construction job, nurses, doctors, and other hospital staff may be working around you. Patients may be close to your activities, and hospital visitors may be walking past your work area. Your construction work is a disruption to the daily operations of the hospital, and you are a guest in the facility.

The pace on a normal construction project is typically fast paced with the goal of fi nishing the project as fast as possible. A hospital project moves at a slower pace and has more phases. Your construction work may have to be coordinated with other, non-construction, activities in the hospital such as critical surgeries being performed close to your work area. The ICRA practices may add steps or phases to your work that are not commonly done in regular construction.

The rules regarding how construction workers behave are also different in a hospital, healthcare or other occupied facility. Hospital administrators do not want to see construction trades people talking to or staring at hospital staff, visitors or patients, even if they are your neighbor, friend or relative.

You should act respectfully toward the hospital staff and patrons. Remember, nobody wants to be in the hospital or be visiting someone in the hospital. It’s a stressful place, and a construction project can make it more stressful. Stay out of the way of hospital staff and activities. This may mean taking the next elevator if the elevator is already occupied. Often times, hospitals restrict the use of elevators to specifi c ones or they can only be used at certain times of the work shift. Avoid conversations with staff and patrons, and don’t stare at patients. Follow all hospital rules, such as no smoking within the hospital. Most hospital campuses are tobacco free and not just smoke free! The use of any tobacco product, including e-cigarettes, on site could be the grounds for termination.

On a hospital project, your work area may be within view of or within earshot of patients, staff, and hospital visitors. What you say in the work area, such as an offensive joke, swearing or inappropriate conversations, may be heard by those

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nearby. Only appropriate language should be used, voice levels should be kept low and obscenities and graphic hand gestures should never be used. Cell phones should not be used within the facility.

Your clothing should be clean and professional: long pants without holes, shirts without offensive messages, and no dangling jewelry. It is important to present a clean and appropriate appearance at all times. This includes good personal hygiene and habits, such as frequent hand washing. Body odors can also be offensive or cause allergic reactions. Body odors can come from colognes, perfumes or tobacco products. Personal grooming, such as washing the body, as well as cleaning and trimming hair and nails are important. Facial hair should be kept neat and trimmed and long hair should be tied back.

And of course you should wear work boots, hard hats, and safety glasses. The ICRA and daily safety briefi ng may require additional protective apparel, such as disposable coveralls, a head cover, or boot covers. Your clothing should be dust-free, especially when leaving your work area - you may need to vacuum yourself off.

The rules often begin with where you can park. Parking is often in short supply at a hospital. You should only park in the areas designated for construction workers. That could be the far corner of the parking lot, so you may need to arrive a few minutes earlier to report to your jobsite on time. Your entry and exit routes to the jobsite must be limited to those pathways that result in the least amount of exposure to patients, staff, and visitors. In addition to the rules above, the hospital may set special policies for your construction project. These may include:

• Requirements to wear ID badges

• A specifi c path through the building for workers, materials, and debris

• An emergency exit route

• The restrooms you can use

• Whether you can use public vending machines

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• Whether you can use their public cafeteria

• Break area locations

• What hours you can work (Maybe the work can only be done at night when there are fewer people around.)

Do not touch or look at medical fi les - get hospital staff to remove paper fi les or shut down computers. Do not share anything you see or hear at a hospital – including something as innocent as seeing someone you know and asking about their treatment. Working around fi le cabinets or computer workstations that contain patients’ medical records creates a legal hazard under HIPAA. HIPAA stands for the Health Insurance Portability and Accountability Act of 1996, a federal law which requires healthcare providers to maintain the security and confi dentiality of patients’ health information. There are serious fi nancial penalties if a hospital violates this law, and you and/or your employer could be sued if you are involved in a privacy violation. You may have to sign the hospital’s internal HIPAA confi dentiality policy.

You may hear alarm color codes, such as “Code Blue,” announced over the hospital’s speaker system. “Code Blue” usually means a patient is in cardiac arrest (having a heart attack). Hospital staff may come running to respond to that emergency, and you need to get out of their way. “Code Red” usually means a fi re alarm. It’s critical not to block, or block open, fi re doors. “Code Green” usually means a utility issue, such as a power failure – many times this is due to construction! But different hospitals may have different codes. These will be explained in a facility briefi ng when you start working on the job. You need to know what these codes mean, and what to do when an alarm is announced. Some codes won’t affect you, but some might require you to evacuate the building.

Working in a health care facility carries with it certain risks, such as potential exposures to infections or diseases. Before working in a health care setting, all of your immunizations should be current. To avoid the spread of illinesses, it is very important not to come to work sick. Additionally, your supervisor should be notifi ed if anyone on your crew becomes sick while working at a health care facility. It should never be assumed that an illness

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contracted while working at the facility is “no big deal”. Something as simple as catching a cold at work may be an indication the precautions are not working. Any illness or infection contracted at the facility should be reported to the infection control department so they can take whatever steps necessary to trace, track and contain any potential outbreaks.

If you have an immune compromised condition, you should consult with your doctor to determine if working in an ICRA environment poses a risk to you, or if your condition poses a risk to anyone in the health care facility. Hepatitis, chronic pneumonia, HIV and asbestosis are examples of immune compromising conditions.

Hazards Unique to Healthcare Construction

Hospitals and other occupied facilities have some potential hazards that you won’t see on typical construction sites. On a typical construction site the mechanical, electrical and plumbing (MEP) systems are being installed or can be locked out to prevent them from being a hazard. In a hospital, the MEP systems are critical, and can’t be interrupted. If you accidentally cut a utility line, you could put patients in danger. During demolition, you may need to use inspection holes or a borescope to confi rm the location of utilities behind walls. Some healthcare construction companies prohibit the use of specifi c tools such as reciprocating saws, or Sawzalls™, for demolition work in hospitals.

Best practices for wall demolition include cutting with a utility knife, removing screws and pulling off drywall panels, and using a manual drywall saw. You may need to protect utility lines with shielding or barricades, in addition to labeling and fl agging them. When you install utility lines, take photos for future reference and mark the location of the lines.

Medical Gas Lines Medical gas lines are an extra utility to be concerned with in hospitals. You may encounter color-coded outlets, and lines inside the walls, for:

• Oxygen (which can be a serious fi re hazard)

• Nitrogen

• Nitrous oxide

• Carbon dioxide

• Low-pressure “medical air”

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• High-pressure “instrument air” (for pneumatic tools such as a dental drill)

• Negative-pressure vacuum (for suction)

It’s usually not possible to have medical gas lines shut down before you begin working near them. As with other utilities on the jobsite, you need to have the lines identifi ed, fl ag them with caution tape, and protect them. You may need to restrict the types of tools that can be used around medical gas lines. Your safety briefi ng should include what to do if a medical gas line is damaged. If a line has been repaired, it must be re-certifi ed by an approved/authorized member of the hospital staff before it goes back in service.

Glass Pipes Hospitals also have clear glass drain lines and vents throughout the facility. These pipes are made of the same extra-strong glass that is used in laboratory glassware. The glass is very resistant to chemicals and won’t corrode, so it is typically used for waste lines in hospitals and laboratories. You should assume that these lines contain hazardous chemicals or biohazards. If you are doing work on a hospital roof, watch out for clear glass vent pipes – they can be diffi cult to see.

Your safety briefi ng should include what to do if a glass drain line leaks, and what protective measures would be required. If you will be demolishing laboratories or removing glass pipes, you must follow special procedures for your protection, including the use of PPE such as protective clothing and a respirator.

HelipadsMany hospitals have helipads, landing areas for ambulance helicopters. The helipad may be on the roof, but it could be in a fl at spot near a parking lot. You can spot the location of a helipad by the orange windsock on a pole that shows the helicopter pilot which way the wind is blowing. When a helicopter is landing or taking off, the rotor blades create downwash, strong air currents that spread down and out in all directions.

If you walk past a helicopter with a load of uncovered construction debris and get hit by downwash, that wind can fl ing your construction debris into the air. Another hazard around helipads is that helicopter downwash blowing on a dumpster can make dust and debris airborne. Construction dumpsters near helipads must always be covered. If your construction project involves a crane or excavator, it must lower its boom when a helicopter is operating nearby, as well as at the end of the shift. Workers using aerial lifts near helipads must also watch for approaching helicopters, the downwash

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could cause the lift to overturn. If you are using an aerial lift when a helicopter is approaching you should lower and move the lift until the rotor blades have stopped.

Hospital Acquired InfectionsHospitals are very concerned about the issue of hospital-acquired infections (HAI). This is when a patient acquires, or gets, an infection inside the hospital. For example a patient is hospitalized because of a heart attack but then develops pneumonia while recovering from bypass surgery. The medical term for these hospital-acquired infections is nosocomial infections. These are also called opportunistic infections.

Hospital-acquired infections are a huge problem. HAIs occur in all settings of care, including hospitals, surgical centers, ambulatory clinics, and long-term care facilities such as nursing homes and rehabilitation facilities. Patients in U.S. hospitals get about 1.7 million hospital-acquired infections each year. Those infections are costing healthcare facilities almost $10 billion and are, more importantly, killing about 99,000 hospital patients each year. It is estimated that 5,000 of those deaths are caused by construction activity in hospitals. Construction dust can kill people in hospitals—that’s why ICRA and infection control practices are so important.

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Chain of InfectionThe spread of an Infectious disease results from the interaction of a pathogen, a host (patient), and an environment. Most of these diseases follow a typical chain of infection that ends with an infected patient. Understanding the chain of infection can help with the prevention of infectious diseases. The chain of infection is made up of six different links: pathogen, reservoir, portal of exit, means of transmission, portal of entry, and the new host. Each link has a unique role in the chain and each can be interrupted, or ‘broken’, through various means.

The PathogenA pathogen is a substance that causes a disease, especially a living microorganism such as a fungus or bacterium. (The plural of fungus is fungi, and the plural of bacterium is bacteria.) Microorganisms are so small that you cannot see them, except with a microscope.

Yeasts, molds, and mushrooms are all types of fungi. Some fungi are useful—we use yeast to make bread and beer, penicillium mold to make antibiotic drugs

Pathogen

Resevoir

Portal of Exit

Mode of Transmission

Portal of Entry

Susceptable Host

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and blue cheese, and we eat many kinds of mushrooms. Mold releases spores that can become airborne when disturbed by activities such as housekeeping, maintenance, renovation, and construction work and even from air fl ow! These spores are easily inhaled and can cause health problems in people who come in contact with them. Serious infection or death can occur when mold spores are inhaled or enter the bloodstream.

Bacteria are single-cell organisms that can also be helpful or harmful. We all have many different species of benefi cial bacteria living in our intestines, which help us digest food. But other types of bacteria can make you sick. They can be resistant to antibiotics and can be easily transmitted through the air, on contaminated surfaces and from person to person. Exposure to bacteria can result from any type of contact, including breathing, touching or ingesting. Most bacteria are opportunistic organisms meaning they can cause diseases in people with weakened immune systems.

Viruses are another type of pathogen, although they are not considered living organisms. Viruses can cause minor illnesses like the common cold, but some cause life-threatening infections, such as liver infections from hepatitis B.

Some common pathogens that are of concern in hospitals especially when disturbed by construction activities are aspergillus and legionella.

Aspergillus The most common cause of construction-related hospital-acquired infections is the fungus aspergillus. Aspergillus is common in the environment. It is in soil, on plants, and in decomposing plant matter. It is also in the dust inside buildings, such as the dust on top of suspended ceiling tiles. Most people breathe in aspergillus spores every day without getting sick. However, people with weakened immune systems or lung diseases are at a higher risk of developing health problems due to aspergillus.

Some fungi reproduce by spreading spores. Fungi spores are like the seeds of plants, except they are smaller and usually just single-celled. But unlike seeds, fungi spores aren’t damaged by drying out, or by extreme temperatures. Some spores are microscopic, and can spread in the air, or be airborne. Dust can be a carrier for fungi spores. Construction dust can spread infection because of fungi spores sticking to the dust particles.

Aspergillus fungus can cause an infection called aspergillosis. This disease usually affects people with weakened immune systems, such as hospital patients. A less-serious form of aspergillosis causes allergic symptoms like coughing and wheezing, but doesn’t invade the body and destroy tissues. Invasive aspergillosis most commonly causes lung disease, but it can spread throughout the body and infect other

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organs. Aspergillosis is usually caused by inhaling aspergillus spores. The very small size of aspergillus spores lets them settle deep into the lungs. A hospital patient could also become infected by spores on dust particles falling out of the air into an open wound or surgical incision.

According to a 2006 report in the Journal of Hospital Infections, medical researchers who traced aspergillosis outbreaks in hospitals found that almost half of those infections were related to construction activity in the hospital. Dust is a prime carrier of aspergillus spores, and construction activities create dust. This is why ICRA procedures to control dust are so critical.

Legionella Legionella is a bacterium that can cause Legionnaires’ disease, or legionellosis. These bacteria were named in 1976, when many people who went to an American Legion convention in Philadelphia got sick from this disease. Legionella bacteria are waterborne – they are found naturally in the environment, usually in warm water. Most people catch Legionnaires’ disease not by drinking contaminated water, but by breathing in mist or water vapor that contains legionella bacteria. The legionella bacteria then grow in the lungs, so most people with Legionnaires’ disease get pneumonia (a lung infection).

Legionella has formed in the water systems at hospitals through cooling towers, condensers, hot water systems, HVAC systems, and even decorative fountains. During construction projects, hospital water systems are often disrupted. If the water is shut off, there could be legionella bacteria that were harmlessly stuck to the inside of a pipe that come loose when the water is turned back on. Shutting off some of the water during construction could create a dead end in the system, allowing water to stagnate and bacteria to multiply. Another source of legionella could be air intakes near standing water on roofs that do not drain properly.

Construction projects uncover reservoirs of pathogens during demolition, renovation and construction; the risk for transmittal must be identifi ed prior to starting any work.

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The ReservoirThe reservoir is the environment in which the pathogen is found. Construction projects uncover reservoirs of disease producing agents during demolition, renovation, maintenance and construction; the risk for transmittal must be identifi ed prior to starting any work. Areas in a hospital that should be considered reservoir areas include:

• Behind drywall

• Ceilings/Plenum spaces

• Ductwork

• Plumbing systems

• Cooling towers

The Portal of ExitPortal of exit means how the pathogen is released into the ambient air. Examples would be opening in walls, doors, ductwork, open ceilings, and plumbing. Proper barriers and work practices can reduce or completely break this link within the chain.

Mode of TransmissionOnce a pathogen is released it can be transmitted over large areas through air current, water supply, construction equipment, carts and debris and clothing of workers. By using best practices such as negative air pressure, barriers and housekeeping would greatly reduce the risk of transmitting infectious agents. Work practices outlined with in the level of ICRA precautions needed for the work being performed should be followed.

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Pathogens are spread by three routes that are a concern for infection control:

1. In the air (airborne)

2. In water (waterborne)

3. On surfaces (surface transfer)

AirborneWhen pathogens become airborne, meaning moved by or through air, they can be inhaled into the respiratory system, ingested or enter the body through open wounds or sores. Pathogens can become airborne through common activities, such as tearing out carpet, grinding, moving ceiling tiles, or cutting into a wall.

WaterbornePathogens can be waterborne, meaning moved by or through water. With any source of water, there is potential exposure to waterborne pathogens. A water supply system can become contaminated in a variety of ways, such as sediment buildup in plumbing, stagnant water or a backed up sewer.

Surface TransferPathogens are transferred by skin or clothing coming in contact with a contaminated surface. Surface transfer can happen at any time, especially during construction, renovation, maintenance and demolition because of the amount of airborne particles that settle out of the air onto a surface.

ICRA deals with all three routes, but a major focus in hospital construction projects will be dust control to prevent airborne transmission of pathogens.

Portal of EntryThe Portal of Entry is the opening that allows the pathogen to enter the host. As construction workers we are not in direct contact with the patients but how we do our work directly affects whether we indirectly expose the patients through the above portals. Improper control at the Portal of Exit is one way the HAI’s are transmitted to the patients via the health care workers, water and HVAC system. Using proper ICRA controls at the Portal of Exit has a tremendous impact on HAIs at the Portal of Entry.

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Susceptible HostA susceptible host is a person who has little resistance against a particular pathogen and who, if exposed to this pathogen, is likely to contract an infection. When healthy people are exposed to small amounts of pathogens, their immune systems can fi ght off the invaders and prevent an infection. But people with weakened immune systems could catch a deadly infection, since their defenses are compromised. The medical term for a weakened immune system is immunocompromised. The following are examples of patients who are immune compromised:

• Patients who have HIV

• Patients with new unknown diseases, or who are receiving new treatments

• Pregnant women

• Newborns, especially those born prematurely

• Elderly patients

• Terminally ill patients

• Patients on specialized equipment, such as dialysis or ventilators

• Patients with open sores, wounds or burns

• Patients undergoing chemotherapy or radiation therapy

• Organ and bone marrow transplant patients

• Patients undergoing steroid, or other treatments for such things as transplants, asthma and rheumatoid arthritis

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Immunocompromised patients are most at risk during construction, renovation and demolition activities. Their immune system is not able to easily fi ght infection, if at all. The ICRA Plan is designed to blend the medical aspects of infection control, or breaking the chain of infection, with the construction practices used on the jobsite.

Developing the ICRA Plan

Infection Control Risk Assessment, or ICRA, is a planning tool that hospitals use to minimize the risks of a construction project causing hospital-acquired infections. ICRA is a systematic method of evaluating the type of construction activity, and the group of patients who could be exposed to infection risks, in order to decide what precautions are required. The results of the evaluation and planning are documented in the ICRA plan.

The ICRA will typically be done by the hospital staff, with input from other parties like architects, consultants, and contractors. In larger hospitals, a team of people may be involved in writing the ICRA: the construction manager, infection control staff, safety staff, epidemiology department staff, and doctors or nurses in charge of the areas under construction. Sometimes a construction company employee, such as the safety manager, might be involved in the ICRA planning, too.

The ICRA process does a lot of things beyond identifying risks. It infl uences design decisions. It sets and communicates expectations from the hospital to the construction contractors. It helps educate and train both hospital staff and you, the construction worker. It tells what equipment you will need for the job, and what instruments you might use to measure the effectiveness of that equipment. It documents compliance with legal requirements as well.

ICRA Precautions

The ICRA plan will include a detailed list of precautions that must be followed before, during, and at the end of your construction project. The key principles for infection control are separation or isolation with barriers, negative air pressure, and housekeeping.

You may not see the full ICRA document on your jobsite, but the list of required infection control precautions will usually be posted at your work area. The ICRA precautions help you do the right thing while making decisions on the jobsite.

As construction workers, you won’t have to do an ICRA on your own. But it’s important that you understand the process, and why you must use particular precautions in

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hospital construction. So before you learn and practice how to use the specialized equipment and procedures for this kind of construction work, we’ll cover why, by reviewing what makes up an ICRA plan.

Different hospitals use different ICRA forms, but they generally follow three steps:

1. Identify the type of construction project activity.

2. Identify the patient risk group that will be affected by construction.

3. Match the type of construction project activity with the patient risk group to fi nd the class of precautions or level of infection control activities required.

The most commonly used tool is an Infection Control Checklist for Risk Assessment and Precautions for Construction & Renovation. The checklist takes the ICRA staff or construction project manager through a series of steps to classify the project and provides mandatory precautions and controls.

Step One

ICRA forms usually use a table that breaks types of construction activity into four categories: Type A, B, C, or D. For step one, look at Table 1 to fi nd the type of construction activity:

Table 1: Construction Activity

Type A

Inspection and non-invasive activities Includes, but is not limited to:

• removal of ceiling tiles for visual inspection only, such as limiting to one tile per 50 square feet

• painting (but not sanding) • wall covering, 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

Type B

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

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Type C

Work that generates a moderate to high level of dust or requires demolition or removal of any fi xed building components or assemblies Includes, but is not limited to:

• sanding of walls for painting or wall covering • removal of fl oor coverings, ceiling tiles, and casework • new wall construction • minor duct work or electrical work above ceilings • major cabling activities • any activity which cannot be completed within a single

work shift

Type D

Major demolition and construction projects Includes, but is not limited to:

• activities which require consecutive work shifts • requires heavy demolition or removal of a complete

cabling system • new construction

Step Two

For step two, look at Table 2 to identify the patient risk group that will be affected by the construction project. This could be areas next door or adjacent to the construction area, or on the fl oor above or below. They could even be some distance away from the construction area, but be connected by the HVAC system, or construction traffi c might pass by them.

Table 2: Patient Risk Group Low Risk • Offi ce Areas

Medium Risk

• Cardiology• Echocardiography• Endoscopy• Nuclear Medicine• Physical Therapy• Radiology/MRI• Respiratory Therapy

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High Risk

• CCU• Emergency Room• Labor & Delivery• Laboratories (specimen)• Medical Units• Newborn Nursery• Outpatient Surgery• Pediatrics• Pharmacy• Post Anesthesia• Care Unit• Surgical Units

Highest Risk

• Any area caring for immunocompromised patients• Burn Unit• Cardiac Cath Lab• Central Sterile Supply• Intensive Care Units• Negative pressure isolation rooms• Oncology• Operating rooms including C-section rooms

Step Three Step three of the ICRA is to match the construction project type (A, B, C, D) with the patient risk group (Low, Medium, High, Highest) on the matrix in Table 3.

Table 3: Construction Project Type

Construction Project Type

Patient Risk Group Type A Type B Type C Type D

Low I II II III/IV

Medium I II III IV

High I II III/IV IV

Highest II III/IV III/IV IV

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Some hospitals use color codes instead of I, II, III, IV. Some hospitals require an infection control construction permit from their infection control department when the class of precautions will be III or IV. Some hospitals organize their ICRA with fi ve classes of precautions: I, II, III, IV, V.

Infection Control Precautions After the ICRA process has decided what class of precautions will be required for the construction project, the hospital will give you a list of specifi c infection control precautions they require. It tells you what you have to do. Table 4 shows an example with different levels of requirements for each class.

Table 4: Infection Control PrecautionsClass During Construction Project Upon Completion of Construction

Project

I

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

2. Immediately replace a ceiling tile displaced for visual inspection.

1. Clean work area upon completion of task.

II

1. Provide active means to prevent airborne 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. Place dust mat at entrance and exit

of work area. 6. Remove or isolate HVAC system

in areas where work is being performed.

1. Wipe work surfaces with cleaner/ disinfectant.

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

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

4. Upon completion, restore HVAC system where work was performed.

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III

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

2. Complete all critical barriers (sheetrock, plywood, plastic) to seal area from non-work area before construction begins, or use control cube method (cart with plastic covering and sealed connection to worksite with HEPA vacuum for vacuuming prior to exit).

3. Maintain negative air pressure within worksite, utilizing HEPA equipped air fi ltration units.


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

1. Do not remove barriers from work area until completed project is inspected by the hospital’s Safety Department and Infection Prevention & Control Department and thoroughly cleaned by the hospital’s Environmental Services Department.

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

3. Vacuum work area with HEPA fi ltered vacuums.

4. Wet mop area with cleaner/disinfectant.


IV

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

2. Complete all critical barriers (sheetrock, plywood, plastic) to seal area from non-work area before construction begins, or use control cube method (cart with plastic covering and sealed connection to worksite with HEPA vacuum for vacuuming prior to exit).

3. Maintain negative air pressure within worksite, utilizing HEPA equipped air fi ltration units.


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

1. Do not remove barriers from work area until completed project is inspected by the hospital’s Safety Department and Infection Prevention & Control Department and thoroughly cleaned by the hospital’s Environmental Services Department.

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

3. Vacuum work area with HEPA fi ltered vacuums.

4. Wet mop area with cleaner/disinfectant.


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Once the appropraite ICRA Precautions have been identifi ed, the ICRA Plan also needs to look at additional precautions that affect the patients. The following steps need to be answered before work begins:

• Step 4. Identify the areas surrounding the project area, assessing potential impact:

• Step 5. Identify specifi c site of activity e.g., patient rooms, medication room, etc.

• Step 6. Identify issues related to: ventilation, plumbing, electrical in terms of the occurrence of probable outages.

• Step 7. Identify containment measures, using prior assessment. What types of barriers? (E.g., solids wall barriers); Will HEPA fi ltration be required?

(Note: Renovation/construction area shall be isolated from the occupied areas during construction and shall be negative with respect to surrounding areas)

• Step 8. Consider potential risk of water damage. Is there a risk due to compromising structural integrity? (e.g., wall, ceiling, roof)

• Step 9. Work hours: Can or will the work be done during non-patient care hours?

• Step 10. Do plans allow for adequate number of isolation/negative airfl ow rooms?

• Step 11. Do the plans allow for the required number & type of handwashing sinks?

• Step 12. Does the infection prevention & control staff agree with the minimum number of sinks for this project? (Verify against Facility Guidelines Institute (FGI) Design and Construction Guidelines for types and area)

• Step 13. Does the infection prevention & control staff agree with the plans relative to clean and soiled utility rooms?

• Step 14. Plan to discuss the following containment issues with the project team. E.g., traffi c fl ow, housekeeping, debris removal (how and when),

Unit Below Unit Above Lateral Lateral Behind Front

Risk Group Risk Group Risk Group Risk Group Risk Group Risk Group

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The hospital’s infection control department will issue an infection control construction permit for your project. This is different from the usual construction permit from local government. It’s an internal hospital document that summarizes the ICRA plan and the infection control precautions that must be used. It’s part of the paper trail proving that the construction project has been reviewed and authorized by the appropriate people. Figure 5 shows an example of an Infection Control Construction Permit.

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Infection Control Construction Permit Permit No:

Location of Construction: Project Start Date: Project Coordinator: Estimated Duration: Contractor Performing Work Permit Expiration Date: Supervisor: Telephone: YES NO CONSTRUCTION ACTIVITY YES NO INFECTION CONTROL RISK GROUP TYPE A: Inspection, non-invasive activity GROUP 1: Low Risk TYPE B: Small scale, short duration,

moderate to high levels GROUP 2: Medium Risk

TYPE C: Activity generates moderate to high levels of dust, requires greater 1 work shift for completion

GROUP 3: Medium/High Risk

TYPE D: Major duration and construction activities Requiring consecutive work shifts

GROUP 4: Highest Risk

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

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

3. Minor Demolition for Remodeling

CLASS II

1. Provides 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 cleaner/disinfectant.


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. 9. Isolate HVAC system in areas where work is being

performed; restore when work completed.

Date Initial

CLASS III

1. Obtain infection control permit before construction begins.

2. Isolate HVAC system in area where work is being done to prevent contamination of the 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. Do not remove barriers from work area until complete project is checked by Infection Prevention & Control and thoroughly cleaned by Environmental Services.

6. Vacuum work with HEPA filtered vacuums. 7. Wet mop with cleaner/disinfectant. 8. Remove barrier materials carefully to minimize

spreading of dirt and debris associated with construction.

9. Contain construction waste before transport in Date Initial tightly covered containers.

10. Cover transport receptacles or carts. Tape covering. 11. Upon completion, restore HVAC system where work

was performed. Date Initial

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Infection Control Construction Permit 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. Do not remove barriers from work area until completed project is checked by Infection Prevention & Control and thoroughly cleaned by Environmental. Services.

9. Vacuum work area with HEPA filtered vacuums. 10. Wet mop with disinfectant. 11. Remove barrier materials carefully to minimize

spreading of dirt and debris associated with construction.


13. Cover transport receptacles or carts. Tape covering. 14. Upon completion, restore HVAC system where work

was performed.

Date Initial

Additional Requirements:

Date: Initial: Date: Initial: Exceptions/Additions to this permit Date Initials

are noted by attached memoranda.

Permit Request By: Permit Authorized By:

Date: Date:

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ICRA Construction Practices

After the project is assigned a class and the appropriate control measures have been determined, construction practices will start by employing three principles used to control the spread of infections: isolation/separation with barriers; negative air pressure and good housekeeping. As we have learned previously, controlling the spread of dust and pathogens from our construction activities can help prevent the spread of infections

Dust/Pathogen Control When working in a healthcare facility, it is important to keep dust and pathogens from transferring through the air. By preventing construction generated dust from entering the public and patient areas, it is possible to minimize the risk of patients contracting infections or illnesses from our construction activities. Something as minimal as lifting ceiling tiles to inspect above a suspended ceiling, or opening access panels, can disturb dust and make it airborne. With ceiling tiles, a good work practice is to mist all four edges with a water spray bottle before you move the tile, to keep dust down. The ICRA might require you to use a containment barrier, even for lifting ceiling tiles. A mobile containment cube is ideal for that requirement.

Cutting or drilling an inspection hole in a wall will obviously create dust and may disturb pathogens inside the wall cavity. Again, dampening the surface with a water spray bottle is a good fi rst step. A drill-through fi tting or PVC tee fi tting on the end of your HEPA vacuum hose is a useful tool for this: you put the fi tting against the wall and run your drill bit through it, so dust is contained and sucked away by your vacuum.

Performing construction, renovation or demolition activities can stir up even more dust and cause pathogens to spread. Water spray can help, as can using hand tools rather than power tools. Demolition using only hand tools can also protect the critical utilities that run through walls and ceilings. Never cut blindly with a power tool into a wall, ceiling, soffi t, or other cavity. Keep your HEPA vacuum Courtesy of Abatement Technologies

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nearby, to vacuum up dust and debris before it can spread. If sweeping with a broom, always sprinkle sweeping compound on the fl oor fi rst, to control dust. Sweeping compound is a dry powder made of sawdust, fi ne sand, and oil or glycerin.

Drywall creates dust from cutting, installation, and sanding. With carpentry work, you’ve got sawdust from cutting and sanding. Sanding for fl oor prep can create major dust. In all cases, using cutting and sanding tools that allow you to attach a vacuum hose makes a big contribution to dust control. Better yet, do as much cutting and sanding as you can in an approved staging area outside the ICRA work area, such as at a loading dock, in the parking lot, or in some unoccupied space.

BarriersThe primary function of a barrier is to control the air quality in occupied areas. Construction areas and projects within a healthcare facility should be isolated from patients and the public. There are many different types of barriers used as part of the ICRA precautions, including mobile containment cubes, soft wall systems and hard wall systems. When selecting a barrier, you need to consider the duration of the construction project, the applicable local fi re codes and the hospital area where it has to be constructed. The ultimate goal for erecting barriers is to prevent the spread of construction dust into the hospital by creating an airtight seal within the work area. Small, short duration projects generating minimal dust may use a mobile containment cube or soft wall system to prevent dust from escaping the work area. Any project that produces moderate to high levels of dust may require a hard wall, dust-proof system, constructed of fi re rated drywall with caulked seams for a tight seal.

Fire codes and building codes also dictate what materials are allowed for temporary construction barriers. The Joint Commission standards for hospital accreditation specifi cally require that temporary construction barriers must be “smoke tight and built of non-combustible or limited combustible materials (drywall) that will not contribute to the development or spread of fi re.” The Joint Commission allows fi re-resistant plastic sheeting for short-term use. But if the project involves activities like torch cutting, welding, or open fl ame, then The Joint Commission says non-combustible barriers should be built.

Barriers can be temporary, such as plastic sheeting, or longer-term, such as a fi re resistance-rated wall built with drywall. Generally speaking, if the project will take longer than one shift, you cannot use a temporary barrier—you’ll have to build rigid walls also called a hard wall barrier.

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Mobile Containment CubesMobile containment cubes are small, single-person containment areas used for inspection work or short-term cavity work. It is a collapsible rectangular cube that measures approximately 4’-6’ x 2’-6’ and rises up to 10’. A containment cube can be on wheels and is easily transported and maneuvered into small spaces. It is small enough to fi t through doorways and into elevators, but big enough to hold a 6-foot or 8-foot ladder inside. Different manufactures design mobile containment cubes in a variety of ways.

The most common design consists of a rolling platform with telescopic poles on each corner that extend vertically to ceiling height. The telescopic poles support a soft sided enclosure made of durable plastic sheeting. The spring loaded poles pop into place and push the plastic sheeting towards the ceiling, creating a seal. This creates a cube that is enclosed on all four sides and sealed along the top edge. Once you have it in position, you lock the wheels, climb inside, and extend the four corner poles to press the top frame against the ceiling. With some models, you can lift the frame and enclosure off the wheeled cart and put it directly on the fl oor.

They are intended to be used with a small negative air machines with HEPA fi lters to manage dust. They have zipper doors on several sides and zippers to open the top of the enclosure. You would most likely use a containment cube for work above a drop ceiling, such as removing ceiling tiles for inspection, running cable, or doing HVAC work. If it has zippered openings on the sides, you can also butt it up against a wall to do wall cavity work. You may need to use tape around the wall opening, to seal the containment cube’s fl aps against the wall. Fold the fl aps inward and tape the fl aps from inside the containment cube.

Containment cubes typically include one or two ports, or tube-shaped openings, near the base of the enclosure to attach a negative air machine. The second port can be used to connect extension cords to tools or to run a HEPA vacuum to vacuum dust off your clothing, your ladder, any tools, and the cube fl oor before you come out.

Courtesy of Abatement Technologies

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Soft Wall SystemsTo enclose a larger work area a soft wall barrier system can be used. A soft wall system is a temporary enclosure with walls constructed of fi re-resistant plastic sheeting. This can’t be just any kind of plastic fi lm – it has to be fi re-resistance rated. So it will usually be 6 mil or 8 mil thick, and treated with anti-static and fl ame retardant coatings. It typically comes in rolls that are 20 feet wide or tall by 100 feet long. This type of barrier system is used for short-term work that lasts no longer than a single shift. The Joint Commission guidelines for hospital construction also say that if a plastic sheeting barrier is temporarily replacing a permanent fi re wall, it cannot substitute for that rated wall for more than eight hours.

There are various methods and materials used to construct a soft wall barrier system. The method and materials used will depend on the situation. The most common construction method uses spring poles to support the plastic sheeting wall. The walls are erected from the fl oor to the ceiling or from the fl oor to the deck. Tape is used to secure the plastic to the ceiling, walls, and fl oor. Some hospital’s ICRA documents may refer to “duct tape,” but you may have to use a tape like blue painter’s tape, to avoid damaging the paint or wall coverings. There is also special double-sided tape that has gentle painter’s tape adhesive on the wall side, but strong adhesive on the plastic sheeting side. Soft wall systems can also use sill seals and metal tracks to help seal the plastic sheeting.


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A soft wall barrier can be confi gured in many different ways, For example, it can be a freestanding structure, or it can be placed against a wall or corner, making it a two- or three-sided structure. It can also be one-sided and used to divide a room.

An entry into the soft walled barrier must be created to access the work area. The type of entry used will depend on the needs of the project. There are two common types of entries that can be used with a soft wall system:

1. Self-adhesive zippers - For a zipper door, you press a self-adhesive zipper onto the plastic sheeting where you want the opening. This creates a resealable doorway. A self-adhesive zipper creates a tighter air seal than a fl ap door.

2. Flap door or a T-door – A fl ap door is created by cutting a vertical slit for the door opening, then using spray adhesive to attach a rectangular sheet of plastic above the top of the slit as a door. To weigh down the bottom edge of the door fl ap, use spray adhesive to wrap up a piece of small-diameter PVC pipe in the bottom edge. The ICRA documents might specify a 2-foot overlap on each side of the opening.

More time may be spent putting up a barrier and taking it down than actually doing the work inside the barrier. That may seem ineffi cient, but remember that your fi rst priority in infection control—to protect patients from construction hazards and dust. A soft wall barrier is also used in an emergency because they can be erected quickly.

Hard Wall BarriersWhen a longer-term barrier is needed for an ICRA job that will take more than one shift, a hard wall barrier or rigid wall using metal studs and drywall will be built. During the time it takes to build a hard wall barrier, a temporary soft wall system may be built fi rst, to contain the dust from your drywall work. Then the hard wall barrier is built inside the soft wall barrier. After the drywall is up, the temporary barrier is vacuumed thoroughly with a HEPA vacuum cleaner and then taken down.

Hard wall barrier systems are used for long-term construction projects that last over multiple work shifts. These systems are also required when performing work in Class


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III and Class IV work areas. As with the other types of barriers, various methods and materials are used to construct hard wall systems. The methods and materials will depend on the specifi c situation within the healthcare setting. The walls of the system are most commonly constructed of metal studs and drywall with a polyethylene covering and insulation, which helps reduce noise transmission from the work area. However, other products may be used to construct the walls, such as oriented strand board (OBS), plywood, fi berglass reinforced plastic or sheet metal.

If the hard wall barrier is in public view, the walls may be taped and painted. It is critical that the barrier be sealed around the perimeter. This prevents air infi ltration or leakage in the contained area. An entry way into the contained area must be created. The type of entry used will depend on the situation. There are three common types of entries used with a hard barrier system:

1. Pre-hung gasketed entry door

2. Plywood door

3. Flap-door or T-door.

In some work areas temporary barriers may not be needed to create a contained work environment. These areas still need to be sealed before being considered a contained area. Using the existing walls and doors may provide a suffi cient barrier to prevent the spread of dust. These areas need to be sealed to prevent contaminated air from entering the clean areas of the healthcare facility. Openings and penetrations can be sealed with tape, caulk, or polyethylene sheeting, depending on the location of the opening. The following are examples of openings and penetrations that should be sealed:

• Joints of unused doors and windows

• Doors to adjoining rooms

• Air vents

• Floor cracks

• Ductwork

• Pipes

• Deck, the actual ceiling above the ceiling tiles

• Wall and ceiling penetrations such as medical equipment, TVs, or computers, electrical devices, switches, medical gas outlets, receptacles and cabling.

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AnteroomsAn anteroom is a contained area that separates the work area from the public or clean patient occupied area of the hospital. As an infection control precaution in hospital construction, an anteroom is a small separate barrier room at the entrance to your work area, with doors at each end. You pass through it to go into your work area, and to go back out into the public or patient occupied areas of the hospital. Using an anteroom will prevent the work area air from escaping the contained area. Another reason to build an anteroom is to help maintain negative air pressure inside your work area. The anteroom has a separate HEPA air machine to create its own negative air pressure. With two doors in an anteroom, only one door is open at a time, so you don’t interrupt or lose the negative air pressure.

The size of the anteroom depends on how it will be used. If it’s main purpose is to keep negative air pressure in the main work area, and contain sticky mats (sometimes referred to as walk-off mats), it doesn’t have to be big. No matter its size, both doors of the anteroom should swing inward. The doors should be self-closing, with a spring, closer, or spring hinges. But remember that equipment, carts, and trash carts (sometimes called trash gondolas) must also pass through the anteroom and its doors. Sticky mats should be placed at both doors.

An anteroom is also used as a changing room to put on Patient Protective Apparel (PPA) before exiting into the clean hospital area. PPA is clothing worn outside of a contained work area to prevent transmitting dust and dirt from workers to patients and to maintain a clean environment in patient occupied areas. Your PPA must be worn when you are walking though patient areas and will be removed in the anteroom before entering the work area. PPA will be used again when you exit the work area and move through the patient areas.

Personal Protective Equipment and Patient Protective ApparelThe use of personal protective equipment (PPE) and patient protective apparel (PPA) on an ICRA construction project has different purposes. There is the PPE you will wear to protect yourself from worksite hazards, hardhat, safety glasses, gloves, etc. There will also be patient protective apparel you will wear to prevent the spread of construction dust when you move throughout the clean area of a hospital. PPE is worn to protect you; PPA is worn to protect the patients, hospital staff and visitors. Courtesy of Abatement Technologies

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The ICRA might require you to wear PPA such as disposable coveralls and boot covers. If you have to pass through a sterile area, the hospital may require you to put on a gown (or even change into scrubs), and wear a cap, mask, and gloves. The PPA for a hospital jobsite may not be as stringent as the PPE used when working around asbestos or hazardous materials, but you still need to follow the proper procedures for removal. Typically, you have to HEPA vacuum or wipe down your PPA/PPE before leaving an ICRA area. When using a HEPA vacuum to clean your clothes in an anteroom, start at the top of your head and work down to your boots. Do not forget to vacuum or wipe down your hard hat (or use a head cover).

If you are reusing PPA such as cloth or paper coveralls, or putting them back on again after a break, vacuum them before taking them off. Do not contaminate clean disposable garments with dirty ones, such as sticking used boot covers in the pocket of clean coveralls.

Removing Coveralls If you will not be wearing the disposable coveralls again, carefully roll them off—DO NOT just yank them off, you can shake dust and pathogens back into the air. Pull the coverall sleeves inside out as you remove your arms. If you were wearing disposable gloves, pull them inside out too, and leave them in the sleeves of the coveralls. Roll the coveralls down past your waist and down your legs, turning them inside out as you go. Pull them down over your boots, turning the boot covers inside out and keeping them inside the legs of the coveralls. Put the coveralls in a trash bag, then in the trash gondola.

Below is a typical procedure workers should follow when entering and exit through an anteroom:

1. Enter the anteroom and close the door.

2. Remove all PPA. Shoe covers may be required to be worn inside the work area.

3. Open the door to the work area and enter the contained area.

4. Complete work tasks.

5. Re-enter the anteroom and close the door.

6. Remove shoe covers, if worn.

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7. Vacuum clothing with HEPA vacuum.

8. Put on PPA, including new shoe covers.

9. Exit the anteroom and close the door.

Hand washing and proper cleaning of clothing are important defenses against the spread of dust and pathogens. Hands should always be washed after leaving the work area and before eating, drinking or using the restrooms. To remove dust from your clothes, you should vacuum yourself with a HEPA fi ltered vacuum before leaving the work area. If your job requires you to perform work activities outside before entering the health-care facility, you should vacuum your clothes before entering the facility. This ensures any dust or dirt on your work clothing does not enter the hospital. It also leaves a good impression on the hospital staff, patients and visitors!

Negative Air Pressure

Preventing pathogens and dusty air from entering a clean environment is a primary concern of a hospital ICRA when construction, renovation or demolition work is being performed in a health care facility. By controlling the air pressure in the work area, we can prevent dust and airborne pathogens from entering public or patient occupied areas of the facility.

When the air pressure within the work area is less than the air pressure outside the work area, negative air pressure occurs. This means that when air is drawn

from inside the work area it creates a vacuum. To achieve a negative air pressure, more air must leave the work area than enters. To make up for this loss of air, clean air is pulled from the public or patient occupied areas into the work area. The purpose for creating negative air pressure in the work area is to ensure dust and pathogens do not end up in



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the clean areas of the hospital. If air is continually sucked in to the work area, dust and airborne pathogens cannot get out.

A HEPA (High Effi ciency Particulate Air) negative air machine is used to pull air from the work area and maintain the desired negative pressure. The HEPA machine also fi lters out the dust and airborne pathogens and then discharges the fi ltered air to an outside area. Negative air machines have different names depending on geographic location, local area preference and historical use. Some common names for a negative air machine include:

• HEPA machine

• Air scrubber

• Hog

• Red Baron® (brand name)

• MicroTrap™ (brand name)

Because negative air pressure is such a key precaution for infection control, the negative air machine has to run continuously during a project. You need to be sure you maintain negative pressure by monitoring:

• That the negative air machine is on. If allowed, the negative air machine can be plugged into emergency power outlets.

• The air fl ow, air pressure, or particle count in the air.

• The condition of the negative air machine’s fi lters.

• The condition of the exhaust duct hose.

It is critical that the correct negative air machine fi lters are used, and changed as needed, so the negative air machine does not blow airborne pathogens out into the hospital.


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Housekeeping

Good housekeeping is essential to minimizing the spread of dust during construction activities. When construction materials and debris starts to accumulate in the work area it is easier for accidents to happen, and for dust to spread outside of the work area even with proper barriers and negative air pressure.

Sticky Mats/Walk-off MatsThe ICRA plan will often require the use of sticky mats at the entrance and exit of the work area. These are fl oor mats covered with a sticky adhesive, which pulls dust

and dirt off the bottom of boots and the wheels of equipment. They come stacked in pads of 30 or 60 layers – when the top layer is dirty and no longer sticky, peel it off to expose a new clean layer. For use on hard-surface fl oors, the bottom of the mat has an adhesive that sticks it to the fl oor. The mat can be secured to the fl oor with spray adhesive (if allowed), to help keep it in place. Based on the fl ooring, you may need to put down a sheet of hardboard to protect the fl oor, and then secure the sticky mat to the hardboard instead. For carpet or wood

fl oors, sticky mats come on a plastic frame or base that has an anti-slip backing rather than adhesive on the bottom.

Another method of removing dust and dirt from shoes, carts and rolling equipment is the use of walk-off mats. Walk-off mats are usually constructed of carpet and are placed in areas where there is a likelihood of a lot of dirt and dust. The carpet squares must be taped down so they cannot slide. Sometimes the carpeted walk-off mat is dampened to ensure dust and dirt is not easily spread away from the work area. However, there is a concern that any moisture, including a damp carpet square, can cause mold, so some hospitals’ ICRA policies do not allow this method. Check with a supervisor or



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hospital staff about using carpet squares. On most jobsites, the walk-off mat is placed inside each exit point to collect larger debris and the sticky mats are placed outside the exit point to trap the fi ne dust and debris. This extends the life of the sticky mat, but you need to vacuum the carpet squares regularly with a HEPA vacuum.

Trash Carts The ICRA plan might also require special handling for trash carts (some areas of the country call them trash gondolas). You may have to use a smaller trash cart than usual, because it has to fi t through doorways and into elevators. That means you’ll be making more trips back and forth to the dumpster—that’s part of the deal with a hospital construction job.

The trash carts should have a solid lid. Otherwise, you will need to tightly cover it with taped-down plastic before rolling it out of the construction area to the dumpster. The lid also needs to be closed, or a cover taped down, for the return trip back from the dumpster. Long pieces of lumber, studs, conduit, or other materials cannot poke out from under the lid of the trash cart. They have to be cut into pieces that will fi t inside the trash cart with the lid closed. If something will not fi t in the trash cart, it needs to be wrapped in sealed plastic sheeting before you carry it through the hospital to the dumpster.

The ICRA plan typically requires the wiping down of the trash cart at each end of the trip, before it leaves the work area, and before it comes back into the hospital from the loading dock or wherever the dumpster is located. In that case, a cleaning station will need to be set up in both places. Try to use cleaner or disinfectant supplied by the hospital, so you know it’s acceptable, and so a new or strange smell isn’t brought into the hospital from different cleaning products.

Equipment CartsEquipment carts, hand trucks and other methods of moving construction materials into and through a healthcare facility also need to be covered or cleaned to make sure dust and outside dirt is not brought into or moved throughout the facility. Just like the trash carts, the ICRA plan requires the wiping down of the materials at each end of the trip, before it leaves the work area, and before it comes back into the hospital from the

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loading dock or wherever the material is located. It’s a good idea to cover your tools, equipment and building materials when not in use. This prevents dust from getting on them and also helps in cleaning the materials before bringing them into the hospital.

Potential Hazards to Workers The work we do in a health-care facility may create infection risks for hospital patients, but a hospital also contains hazards that could affect your health and safety.

Biohazards Used needles and scalpel (surgical knife) blades are a biohazard for exposure to bloodborne pathogens, such as hepatitis A or B (a liver disease) or HIV. The medical term for this kind of waste is sharps. There are special red plastic or metal boxes, called sharps containers, to safely dispose of these materials. Sharps containers should be removed before any work begins. If you fi nd a sharps container, contact the hospital staff to have it removed before you begin work.

Soiled linen is another biohazard in hospitals. Bed sheets, towels, and clothing may be contaminated with blood or other bodily fl uids. Some hospital laundry may be in red plastic bags or carts as a warning that it contains infectious materials. As with sharps containers, do not handle any red biohazard materials or containers. That is the responsibility of hospital staff.

You should always assume that surfaces that have been in contact with patients might be contaminated. Spores from bacterial pathogens, such as Methicillin-resistant Staphyloccuc Aureus (MRSA) and Clostridium diffi cile (C. diff.), can live for months on contaminated surfaces. Do not touch wheelchairs, beds, or the like in a hospital.

Asbestos and Lead In older hospitals (those built before 1980), there may be asbestos in pipe insulation, as well as lead pipes, lead solder, or lead paint. If asbestos or lead has been identifi ed where you need to do work, the hospital must have trained professionals remove those hazards before you begin your work. Asbestos and lead abatement requires specialized training and equipment, and would be a separate stage in a hospital construction project, done by a trained, qualifi ed, and authorized contractor before you begin your work.

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Mold When performing construction or renovation work in a hospital or health-care facility it is not uncommon to fi nd mold. Hospitals and healthcare facilities have all of the necessary ingredients for mold to grow! Mold could be growing in sinks, bathrooms, drains, or other damp areas. Mold can also grow on damp drywall. Sometimes the mold will be visible on the outside walls but most often, mold is found inside the wall cavity or ceiling plenum. Like aspergillus, the concern with mold is inhaling airborne mold spores. Exposure to mold can cause allergic reactions, irritate your eyes, nose, or throat, or cause lung infections. You need to wear the proper PPE around mold. Any new installations in wet or damp areas should be done with mold or moisture resistant products.

Medical Equipment Medical equipment in a hospital can be dangerous for construction workers. Radiation exposure is a concern around X-ray machines or CT scanners. MRI scanners create extremely strong magnetic fi elds that can disrupt implanted medical devices like pacemakers, cochlear implants, or insulin pumps. When an MRI scanner is running, the magnetic force can pull metal materials into the magnet. There may be a “gauss line” marked on the fl oor, warning of a perimeter beyond which ferromagnetic items

are strictly prohibited. The warning line may extend outside of the MRI room, depending on the shielding in place. Get too close, and an MRI’s magnet can pull a watch off your arm, rip a tool out of your hand, or even pull something as big as a vacuum cleaner or fl oor buffer across the room. Remember, an MRI machine usually runs continuously, including after hours and weekends, so

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extreme caution must be taken when you are working near them. You don’t want to risk injury – or damage a multi-million dollar piece of equipment. Be aware and follow signs.

You can be struck by traffi c in hospital hallways. Wheelchairs, beds, and gurneys (wheeled stretchers) are rolled down hospital hallways. So are housekeeping and maintenance carts. In an emergency, hospital staff might be running down the hall with a patient on a gurney or with emergency medical equipment such as crash carts or isolation carts, so you need to pay attention to your surroundings.

On the roof, you must be careful of exhaust vents from the hospital laundry or laboratories. A special hazard on hospital roofs are exhaust fans from infection isolation rooms, which will be marked with biohazard labels.

As we’ve mentioned before, hospitals expose you to some unique hazards you do not usually encounter on a typical jobsite. Pay attention to warning signs.

Interim Life Safety MeasuresInfection control work does not end with building a barrier and creating negative air pressure inside the barrier. You have to keep watching for potential hazards that could develop while you are working.

Interim Life Safety Measures (ILSM) are health and safety measures that are put in place to protect the safety of patients, visitors, and staff who work in the hospital. The responsibility for identifying fi re, safety and security measures belongs to the ILSM team. The ILSM team works in conjunction with the ICRA team. Construction activities can affect the life safety systems in a hospital. For example, the fi re sprinklers may need to be shut off where work is being done. A construction project may require

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temporary exits, temporary fi re alarms, and warning signs. The hospital will decide what interim life safety measures are required for your project.

The hospital or your construction company may use a daily inspection checklist to monitor Interim Life Safety Measures (ILSM) and ICRA precautions. This checklist is an effective tool for catching potential hazards before they become big problems. The checklist could include items such as: exits, fi re equipment and fi re safety, general safety hazards, and ICRA precautions. The hospital may also do their own inspections of the construction area for interim life safety measures. An example of an ISLM checklist is shown on page 46.

Another method for catching potential hazards before they become big problems is to quickly scan the work area from top to bottom, from the ceiling to the fl oor, looking for hazards like new holes or penetrations in a barrier, water leaks, dust or debris, or safety issues unique to hospitals. This informal method can be done by everyone on the jobsite. By paying attention to your surroundings and applying common sense, you can help ensure everyone’s safety is considered during the construction project. The following are things to consider within your jobsite that support the ICRA plan or ILSM. If you see something that doesn’t look right, report it to your supervisor or the hospital ICRA supervisor.

Ceilings• Missing or open ceiling tiles can let dust that has accumulated above the ceiling

fall into the work area.

• Wet ceiling tiles indicate a leak or a moisture source that creates potential for mold growth.

• Holes or penetrations in the containment barrier, such as pipes, ducts, or conduit, need to be sealed off.

• Fire sprinkler heads need to be protected with cages or covers and fl agged with caution tape.

• Light fi xtures, exit signs, and smoke detectors need to be covered with sealed plastic sheeting or plastic bags.

• Construction activities can stir up dust accumulations inside ductwork.

• An open ceiling can create a breach in a fi re barrier.

Walls• The existing air supply and return vents need to be covered, and stay covered,

with vent mask fi lm or solid covers. If you are using return vents for negative air

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pressure, they should be covered with two layers of fi lters.

• As you open up ceilings, you may fi nd open walls above the ceiling grid. They need to be sealed to return the wall to its original fi re rating.

• If you are demolishing walls, you need to seal as you go, closing off pipes, ducts, or conduit so you do not contaminate them with dust, and so they do not compromise negative air pressure.

• If you penetrate a fi re barrier wall, or your own construction barrier, with a new hole, you need to seal it with a fi re-rated assembly or fi re caulk.

• If you are putting up new permanent drywall, you should clean the wall cavity before closing it up, to eliminate any sources of potential mold growth on the new drywall.

• You should hold new drywall 3/8 of an inch above the fi nished fl oor (baseboard or molding will cover the gap later). This will prevent moisture on the fl oor from wicking up into the drywall, possibly causing mold growth.

Doors and Windows • Keep doors into your work area closed at all times. An open door weakens

negative air pressure and lets dust out of the construction area. An open door also risks unauthorized people wandering into the work area.

• Windows need to be kept closed at all times, to maintain negative air pressure, keep dust contained, and keep out moisture.

• If the exhaust fl ex duct from a negative air machine is routed out a window, you need to seal around it to keep out insects, birds, or mice.

• In older hospitals, there might be a risk of lead paint on the window frames or asbestos in caulk or insulation around the windows. Notify a supervisor if you suspect the presence of lead or asbestos.

Floors • If you see water on the fl oor, something is wrong. Did a fi re sprinkler head go off?

Is a pipe broken? Besides being a slip and fall safety hazard, wet fl oors can create mold growth.

• Dust on the fl oor needs to be cleaned up with a HEPA vacuum. Footprints at the entrance to the work area, either inside or outside the barrier, indicate that sticky mats are no longer working and need to be changed, and housekeeping needs to be addressed.

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• Holes or penetrations through the fl oor also create issues with negative air pressure and fi re safety. Pipes, ducts, or conduit coming through the fl oor must be sealed so you do not contaminate them with dust, and so they do not compromise negative air pressure. Holes in the fl oor need to be sealed with a fi re-resistance rated assembly, such as fi re caulk, that also has a W rating for water resistance.

Break Areas• You should use only the break areas designated by the hospital, and not eat

inside the work area. Crumbs from snacks or lunch could become sources of mold, carriers for pathogens, or attract insects or mice.

• In the break area, there should be a trash can with a plastic bag liner dedicated for food waste only, kept separate from construction waste.

Posting Signs An important element of ICRA Precautions is the posting of appropriate signs at the entrance. In addition to the usual construction site caution, warning, and directional signs, a copy of the ICRA document or infection control construction permit that lists the required infection control precautions for the project should be posted. Anyone coming into the work area needs to know those requirements for barriers, negative air pressure, trash handling, and PPE. Some construction companies or hospitals will post a log sheet of negative air pressure readings next to the air pressure meter, if the meter is mounted on the barrier wall. If construction activity changes the normal traffi c fl ow through the hospital, there should also be signs marking the temporary emergency routes or exit routes. It’s also a good safety practice to post the names and phone numbers for the emergency contact people at the hospital and at your construction company.

SummaryProtecting health-care workers and patients from construction generated dusts is an additional precaution that exists when performing construction, renovation and demolition work at health-care facilities that does not exist within other types of construction projects. Conducting an Infection Control Risk Assessment (ICRA) in a healthcare organization is essential for minimizing the risks of acquiring and transmitting infections. It requires the commitment of everyone on the job to understand the unique differences between a typical construction project and health-care construction, comply with the necessary ICRA and ILSM control measures and conduct themselves in a professional manner.

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Daily M

onitoring: ILSM – IC

RA Precautions

Date of assessm

ent/surveyA

ssessment com

pleted by:A

rea assessed/surveyedD

ate distributed to safety/IC:

Project no.Project nam

e:Yes

No

NA

List tim

e, documentation or action/

follow-up as needed

A.

EX

ITS

1. Exits provide free and unobstructed egress through construction.

2. A

lternative exits are clearly identifi ed.

3. M

eans of egress in construction area inspected daily.

4. Free &

unobstructed access to ED/Services and for em

ergency forces.

B.

FIRE

EQ

UIPM

EN

T AN

D SA

FET

Y5. .Fire alarm

s, detection, and suppression systems are in an operational function.

6. Fire alarm

s, detection, and suppression systems are not im

paired.

7. Tem

porary fi re alarm, detection, and suppression system

s been inspected and tested m

onthly.D

ate:

8. Training and additional fi re equipm

ent been provided for personnel.

9. Pow

er has been properly secured at the end of each workday.

Participant Manual

47


Dai

ly M

onito

ring:

IL

SM –

ICR

A Pr

ecau

tions

Dat

e of

ass

essm

ent/s

urve

yA

sses

smen

t com

plet

ed b

y:10

. N

o sm

okin

g po

licy

been

impl

emen

ted

in a

nd a

djac

ent t

o th

e co

nstru

ctio

n ar

eas.

11.

Con

stru

ctio

n ar

eas a

re fr

ee o

f sto

rage

and

hou

seke

epin

g m

ater

ials

, foo

d w

aste

, an

d de

bris

for d

aily

ope

ratio

ns to

redu

ce fl

amm

able

and

com

bust

ible

fi re

load

of

the

build

ing;

fl oo

r are

a le

adin

g to

/from

con

stru

ctio

n si

te c

lean

ed d

aily

.

Dat

e or

tim

e:

Yes

No

NA

Lis

t tim

e, d

ocum

enta

tion

or a

ctio

n/fo

llow

-up

as n

eede

d

12.

Ther

e ha

s bee

n a

min

imum

of t

wo

fi re

drill

s con

duct

ed p

er sh

ift p

er q

uarte

r.D

ate:

13.

Num

ber o

f haz

ard

surv

eilla

nce

insp

ectio

ns in

con

stru

ctio

n ar

ea h

as in

crea

sed.

Last

dat

e or

tim

e:

14.

Safe

ty e

duca

tion

prog

ram

s hav

e be

en c

ondu

cted

to e

nsur

e aw

aren

ess o

f any

IL

S Sa

fety

Cod

e de

fi cie

ncie

s and

con

stru

ctio

n ha

zard

s.D

ate:

C.

HA

ZA

RD

SU

RV

EIL

LA

NC

E a

nd IN

FEC

TIO

N P

RE

VE

NT

ION

SA

FET

Y15

. Po

wer

is p

rope

rly se

cure

d at

the

end

of e

ach

wor

kday

.

16.

Han

d an

d sa

fety

rails

are

in p

lace

and

in g

ood

cond

ition

.

17.

Exte

nsio

n co

rds a

re g

roun

ded

and

in g

ood

cond

ition

.

18.

Pow

er to

ols a

re in

goo

d co

nditi

on.

19.

Wor

kers

wea

ring

requ

ired

iden

tifi c

atio

n an

d ha

rd h

ats a

re u

sed

as re

quire

d.

Participant Manual

48


Daily M

onitoring: ILSM – IC

RA Precautions

Date of assessm

ent/surveyA

ssessment com

pleted by:20. C

utting and welding operations are properly and safely conducted and have

appropriate hot work perm

its.

21. Docum

entation of worker instruction in R

ight-To-Know

, Infection Control

and Fall hazards is available if requested.D

ate of request:

22. All scaffolding com

plies with O

SHA

requirements (1926.451).

23. Construction site secure and properly isolated from

fresh air intakes.

24. Lock out / tag out procedures are used as appropriate

YesN

oN

AL

ist time, docum

entation or action/follow

-up as needed

25. Materials used (i.e., fi re retardants) com

ply with necessary safety regulations.

26. Construction barriers m

aintain negative pressure relationships.

27. Workers dem

onstrate compliance w

ith traffi c patterns.

28. Workers com

ply with use of PPE (H

ard hats, eye protection etc) as needed.

29. HEPA

fi ltration units, HEPA

vacuum equipm

ent, &/or continuous use of

exhaust fans demonstrate they are functioning appropriately.

30. Exhaust ducts sealed/capped as agreed by ICR

A.

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49


Dai

ly M

onito

ring:

IL

SM –

ICR

A Pr

ecau

tions

Dat

e of

ass

essm

ent/s

urve

yA

sses

smen

t com

plet

ed b

y:31

. C

onst

ruct

ion

area

doo

rs a

re c

lose

d an

d ga

sket

s & h

ardw

are

are

inta

ct.

32.

Con

stru

ctio

n ca

rts tr

ansp

ortin

g de

bris

are

cov

ered

and

con

sist

ent w

ith

agre

emen

t des

igne

d to

min

imiz

e ai

rbor

ne p

artic

ulat

e m

atte

r fro

m d

ebris

.

33.

All

win

dow

s and

doo

rs re

mai

n cl

osed

to p

reve

nt c

ircul

atio

n of

dus

t/deb

ris.

34.

Wal

k-of

f mat

s, ad

hesi

ve st

rips a

re c

lean

and

cha

nged

suffi

cien

tly, o

r co

nstru

ctio

n ex

it cl

eane

d su

ffi ci

ently

to m

aint

ain

clea

n en

try/e

xits

.

35. N

o si

gns o

f wat

er le

akag

e or

pes

ts.

36.

Cei

ling

tiles

repl

aced

whe

n sp

ace

not b

eing

acc

esse

d.

Participant Manual

50


Participant Manual

Documents

INFECTION C R ASSESSMENT (ICRA) AWARENESS · 2019-03-29 · CPWR developed this eight hour Infection Control Risk Assessment (ICRA) Awareness program to assist North America’s Building