Breaking the Chain: How to Better Contain Infection Risk During Hospital Construction

Construction is a dirty business. All sorts of dust, debris, concrete, and wiring will be part of any expansion. When a hospital is adding onto an existing department or is making changes within that department, it is often referred to as a phased build. When engaging in a phased build, hospital administrators, infection preventionists, and other staff must deal with the threat that the construction could spread contaminates into adjacent areas. Early discussion and risk assessment associated with the type of construction, scope of construction, and length of construction is key to minimizing the potential impact.Do not lose sight of the fact that many patients and families spend time adjacent to these areas.

Construction in healthcare happens for a reason. Most likely it is driven by growth, regulations, or improving the patient experience. Hospital administration should identify key stakeholders and subject matter experts who have relevant knowledge of the expansion being considered. The most important area of concentration is keeping in mind that the goal is best outcomes for patients. If best patient outcomes are the deciding factor, decision making becomes much easier. For example, it may be necessary to change materials flow near a construction zone in order to keep consistent separation between clean and dirty materials. If patient flow or experience is impacted by the need for new materials or pathways, the safety and experience of the patient should be the most influential factor in decision making. 

Renovation or construction that happens in preexisting spaces or occupied areas have very different sets of challenges than the building of new facilities. The current phase of the construction and the assessment of risk will help determine necessary intervention. Demolition, for example, in the existing or adjacent areas creates dust and debris. It also creates a need to remove construction debris from the site to an appropriate disposal location. In some cases, thousands of pounds of concrete, dirt, and other contaminates will need to be moved from point A to point B. During construction planning, ensure that the commingling of pathways of construction materials is minimized with clean pathways and patient transport.

After demolition, the project moves into an active construction phase. Have you ever sanded or seen someone sanding drywall? After a short time, the person looks like they have been covered in baby powder. Hopefully the individual is wearing a mask that keeps he or she from inhaling the dust. Imagine the amount of drywall dust that is produced in a large expansion. All of that fine particulate has to go somewhere. What happens to all that dust in an adjacent construction zone? These are just some of the considerations the group-and especially infection preventionists-should address in order to contain possible contaminates that become more prevalent during construction in pre-existing departments.

Construction contaminates follow a similar pathway as the chain of infection. The illustration of a chain is often used to show how illness can be transmitted between individuals. Most importantly, the illustration also indicates that if a link of this chain is removed, then the cycle of infection is broken. Imagine infection prevention during construction and breaking the chain. If the “EXIT” link is properly managed, it can minimize or prevent issues downstream. Concentration on the first 3 links in the chain is important; these 3 links are the most actionable when dealing with infection control risk during construction.

1. Infectious agent 

2. A reservoir 

3. Portal of exit

4. Mode of transmission 

5. Portal in entry

6. A new host

Risk 1: Agents, more precisely infectious agents in a construction zone, are not difficult to find. Spores, bacteria, and molds are readily found in air and soil. Many of these common contaminants are harmless to most people with healthy immune systems. Focus on the patient. Patients in healthcare are diverse and their healthcare needs vary drastically. Patients may have suppressed immune systems, respiratory issues, or other comorbidities that could place them in a higher risk category for getting an infection than that of a healthy individual. Hospitals manage the risk of transmission on a daily basis as part of their current infection control and cleaning protocols. Daily hospital practices are focused on the current state of business. When a construction project is added to the mix, special attention needs to be taken to identify the risk of possibly increasing the presence of these infectious agents.

Risk 2: In the infection control chain, a reservoir is an object or person that agents can attach to and live on. During a construction project, there are limitless reservoirs moving in and out of the construction zone with great frequency. Retained agents on individuals clothing, wheels on carts, and work boots all need to be evaluated. These reservoirs are an essential part of the construction business and cannot simply be removed. The goal in this situation is mitigating the risk of spread by addressing the next link in the chain, the exit.

Risk 3: The exit link in the infection control chain cannot be overemphasized as a key area of attention. If all construction projects could be contained in an airtight bubble and all reservoirs never left the bubble, contamination would be eliminated. In reality we all know that this scenario is impossible. Assessing the exit link is critical because it is the link of infection prevention that during construction projects is most actionable. Countless steps could be taken to eliminate exit risk. However, there also needs to be an awareness that the institution needs to remain operational. Restricting material flow patterns is a potential risk management strategy. Design and communicate to key individuals pathways that prevent commingling of construction reservoirs with clean and patient pathways. Consider designating an elevator for construction use while the highest risk materials are being transported in and out of the facility. When addressing foot traffic, asses the benefit of clean mats at entrance and exit points. Once heavy construction and demolition have been completed, removable shoe or boot covers are another means to limit contaminants from leaving the construction zone. Ensure collaboration between infection preventionist and environmental services to assess the need for additional floor cleaning and surface cleaning during the extent of the project. When appropriate, separate construction zones with sealed walls in order to eliminate airborne contaminates from exiting the zones. If appropriate use high-efficiency particulate air (HEPA) filtration in order to reduce airborne particulates in the construction zone.

Many of these considerations also bring temporary challenges to daily operations. When pathways are closed and elevators are dedicated, it impacts staff and the patient experience. Ensure key stakeholders that these changes are important for patient and staff safety. The inconvenience is only temporary and the need for containment is crucial.

Construction is a dirty business, but also a doorway to potential change. During the construction planning, infection preventionists, hospital administrators, and others on the frontlines of infection control should take a moment to consider the future state of the new space. Infection prevention is an ever-changing world. Careful design of the new space can eliminate need for construction in the future and improve the facility’s ability to carry out effective infection control in the long run. Considerations during planning could include adequate storage and the availability of personal protective equipment. Ensure isolation signs are placed at focus points. Ensure that hand hygiene can be performed easily and is readily accessible. What might seem like a small consideration during the planning of a new space might have the most significant impact to operations and patient safety for years to come.

As healthcare providers, the goal should be zero patient harm. Timeouts, patient verification, and medication reconciliation are some of the safety standards clinicians exercise every day. Ensure the individuals on the construction team, especially those who are not clinicians, have a reverence and acknowledgment that lives are potentially at risk and that they are making the difference. 

Bio: Christopher Whiting is the sterile processing manager at Nationwide Children's Hospital in Columbus, Ohio. He has been in the field of sterile processing for 22 years. Whiting graduated from Bowling Green State University with a bachelors in English and Sociology. He is a CRCST and vice president of the Mid-Ohio Central Service Professionals chapter of the International Association of Healthcare Central Service Materiel Management (IAHCSMM).