Infection Control Today - 07/2003: Control the Chaos

Control the Chaos and the Spread of InfectionDuring Construction

By Kelly M. Pyrek

Controlled chaos. Thats the way many hospitalsdescribe their construction and renovation projects.

Healthcare construction industry expert WayneHansen, PE, REA, CEM, says there are ways healthcare facilities can mitigate thechaos and emphasize the control, especially of the transmission of particulates,bacteria and fungi that can trigger nosocomial infections.

The first and most important step, Hansen says,is achieving consensus on expectations, goals and strategies for completingconstruction or renovation projects without endangering the safety of patientsor hospital personnel.

Ive seen healthcare facility administratorsbrought to the table still kicking and screaming over costs related to infectioncontrol measures during construction activity, he says. Unfortunately, afew had to be brought to the table because of litigation. I hate to see that.

Hansen encourages infection control practitioners(ICPs) to take the lead in helping the construction project team cope with andmanage the process.

He says ICPs know instinctively what must be doneto protect patients and staff from situations such as an outbreak of nosocomialAspergillosis.

Whats the cost for something like that?Hansen asks. Hospitalacquired infections can cost thousands or hundreds ofthousands of dollars, as can remediation of the source of the problem, and theICP has a good feel for what must be done to try to prevent these circumstances.The only way to make it happen is to bring in the administrator, the ICP, theengineer, the risk manager, the employee health designee and anyone else havingto do with the burgeoning costs of workers comp claims. I know of onehospital alone that had to increase its workers compensation by $5 million tohandle complaints. Thats where the ICP almost needs to be an insurancespecialist.

Hansen continues, The ICP must take the leadin saying, We must plan this construction/renovation project in a smartfashion. I think if ICPs, with their defined interests, call a meeting andsay, This is what we have to accomplish, they can offer a value-addedservice to their hospital.

In many hospitals, weve seen a hugeturnaround in attitudes between ICPs and construction and engineering personnel,Hansen adds. Years ago they were at loggerheads. Now they are sitting down todiscuss issues. If you get people with different perspectives to come to thetable, you can make good things happen.

The Contaminants

Construction and extended maintenance projectsin a hospital provide the greatest potential for introducing contaminants thatcan lead to nosocomial infections, writes Hansen in the book he edited, InfectionControl During Construction: A Guide to Prevention and JCAHO Compliance. Allbuildings, including hospitals, harbor biological pathogens in the cavities ofwalls, floors and ceilings. Whenever these cavities are penetrated and the airin them disturbed, the risk of aerosolizing these pathogens is high. Aninfectious containment and environmental monitoring program must be establishedto eliminate or minimize the incidence of nosocomial infections associated withconstruction or repair projects. Every organization must assess the level ofprotection needed for the various construction, repair, replacement andmaintenance activities that will be undertaken in the hospital.

Hansen outlines a list of common contaminantsgenerated during construction or renovation:

• Inorganic nuisance dust and respirable dust that can cause eye and throat irritation and general discomfort

• Fibers that can be a source of mechanical irritation to mucous membranes

• Chemical odors (often caused by microbiological contamination) that can be hard to trace

• Microbiological contaminants that include bacteria and fungi In healthcare facilities, opportunistic infection caused by exposure of highly susceptible patient populations to environmental organisms such as the fungus Aspergillus and the bacteria Legionella is of critical concern, according to Philip R. Morey, PhD, CIH, director of microbiology and IAQ and vice president for AQS Sciences and a contributor to Hansens book.

In healthcare facilities with highly efficientHVAC system filters, the total concentration of fungi in the indoor air isgenerally much lower than that found outdoors, Morey writes. Transportationof debris, soil and dust associated with construction often leads to indooraccumulation of Aspergillus and Penicillium species, especially in flooringsystems. The growth of fungi in buildings is primarily dependent on the presenceof moisture on the surfaces and in the capillary spaces of construction andfinishing materials. Moisture problems and consequent fungal growth can occur inbuilding components such as the building envelope, porous materials in damplocations and paper facers of gypsum board.

Morey explains that Legionella and othergram-negative bacteria can grow in the water systems of hospitals, including incooling towers, evaporative condensers, hot-water storage and transport systems,whirlpools and steam rooms that are maintained at lukewarm temperatures.Additionally, species of Pseudomonas and Flavobacterium can grow in stagnantwater such as humidifiers and water spray systems, or on wet HVAC systemsurfaces such as cooling coils and drain pans. The occurrence of a biofilm ona wet surface is a certain indication of poor maintenance as well as theoccurrence of gram-negative bacteria and other microorganisms, Morey writes.

Mold has been a hot topic in healthcarefacilities as well as in residential and commercial dwellings with the recentonslaught of highly publicized mold-related litigation.

Mold is the next asbestos, Hansen saysemphatically. Its the perception of mold and what it can and cant dothat seizes the imagination. The fact that the occurrence of allergies andasthma is increasing exacerbates the issue. People who have never had allergiesor asthma are suddenly getting these conditions and people are blaming it on thebuildings they occupy, whether its right or wrong. You hear about big moldcases like Erin Brockovich or Ed McMahons and it stirs up a lot of awarenessof mold on the part of the general public. I do expert witness work for thelegal industry and almost all of it is about mold. Its a huge issue.

The Horror Stories

Hansen has seen his share of horrors in crawlspaces, between walls and above ceilings, and says the presence of contaminantsis a given.

Whatever is outside and we know thingslike fungi are rampant outside comes inside, he says. Most of it isno-see-um, so no see-um, no-clean-um. Everyone has seen pictures of thehorrors contained in ceiling cavities, and construction and engineeringprofessionals know you have to clean the wall and ceiling cavities before theyare buttoned up. The reason is, no matter how careful you are with constructionyou are going to have leaks. So you have to open up a wall and fix the pipes.Whatever is in the wall is now colonized and growing. And think about the numberof times routine maintenance involves the ceiling, whether its changing lightfixtures, changing out damper controllers, and every time, that reservoir isdisturbed.

The air gets stirred up because duct leakagecreates air currents and lights create heat and a rise in the air. All of theseactivities are keeping that mold and whatever else is up there moving around andairborne.

Hansen says many healthcare facilities areplagued by birds and rats that find their way into ventilation-system spaces.

Its difficult to go into any hospital and notfind some evidence of pests and rodents someplace in the building, Hansensays. We have found some strange things in ceiling overheads.

He recalls the time when an electrician entered aceiling overhead, grabbed a conduit to pull himself up and it moved. Hediscovered it was a 25-foot python.

At least there were no rats, Hansen says,laughing. Wildlife in the overhead is a fact of life. We find rodents,crickets, cockroaches and all kinds of insects, and birds, to a lesser degree.Weve had some nasty things happen when walls and undisturbed spaces areopened up.

The Clean-up Process

The most important components of fungi clean-upare physical removal of colonized materials; removal of settled dusts containingspores; prevention of spores and dusts generated during clean-up from enteringclean areas and patient rooms; and the use of appropriate personal protectiveequipment (PPE) by knowledgeable clean-up personnel.

Healthcare facilities should have policies andprocedures for fungi remediation and should include, at minimum, the followingcomponents:

• A description of the general mycological condition in the building General practices to be used for removing contaminated materials and control of construction or renovation dust

• Specific practices to be used in mold clean-up or during dust control

• Specific practices to be used for preventing cross contamination between contaminated or dusty areas, and clean areas and patient rooms PPE and practices to be used by clean-up personnel

• Location of patient areas, notably those with patients who are most susceptible to infection

• Qualifications of clean-up personnel

• Guidelines to be followed by the occupational health professional who is monitoring clean-up activities

Specific actions to prevent cross contamination during construction or renovation activity include:

• Techniques required to prevent fugitive dust emissions from the activity area

• Monitoring procedures needed to verify that work areas are depressurized relative to areas immediately outside of containment

• Administrative controls designed to prevent tracking dust and other contaminants into patient areas Hansen says it is vital to keep construction personnel and healthcare workers from inadvertently tracking on the floor or dispersing through the air construction- or cleanup-related contaminants.

Nurses are generally more aware of crosscontamination than the doctors, Hansen says. When I talk to ICPs, ofcourse, I am preaching to the choir. Nothing can be 100 percent foolproof. Wevehad some hospital administrators who have said, I want my hospital to betotally contaminant free. Well, you cant do that with construction. Giventhe best cooperation between the contractors and hospital personnel theresalways going to be breaches; sometimes they are caused by healthcare staffmembers.

Theyll say, Oh, whats going on in there,Ill just move this yellow tape and walk in and see. I hate to throwstones, but the doctors are a bigger offender than nurses. You can tell a chargenurse, Dont go in here because its contaminated and it might put yourpatients at risk, and theyre not going to go in. But the doctor alwayswants to see whats going on. Youre going to get someone who wants to takea shortcut and youre going to have honest accidents. Those things do happenand theres no way to make it 100 percent foolproof but we can get close.

Lack of Standards

If it seems challenging to establish consensusamong construction team stakeholders, consider that there is no consensus in theindustry regarding indoor air quality (IAQ). The proposed IAQ rule from theOccupational Safety and Health Administration (OSHA), first introduced in 1994,is no closer to adoption almost a decade later.

The IAQ was sandbagged by the tobacco industryand it didnt finish its tour in the Clinton administration, Hansen says.And then the Bush administration just shut it down. The next thing that couldhappen is the introduction of an IAQ standard being worked on by theInternational Organization for Standardization for the last nine years. They aregetting closer to releasing a document, but since the ISO is very slow andmethodical, the standard wont be bulletproof but awfully close. My guess iswe might see a standard in late 2004 or 2005.

The American Society of Heating, Refrigerationand Air Conditioning Engineers (ASHRAE) has its standards related toconstruction, renovation and infection control, as does the Centers for DiseaseControl and Prevention (CDC). The American Institute of Architects (AIA), whose Guidelinesfor Design and Construction of Hospitals and Healthcare Facilities, compiledwith assistance from the Department of Health and Human Services, places newemphasis on designing out potential issues associated with above-ceilingcontaminants and paying attention to ventilation rates in patient rooms. Itsan emphasis reflected in the Joint Commission on Accreditation of HealthcareOrganizations (JCAHO)s revised Environment of Care standard, but real-worldpursuit of this standard is another thing altogether.

While a visit from JCAHO can strike fear in thehearts of hospital administrators in general, Hansen says the message ofmandating construction- related infection control measures is not gettingfiltered down to the individual surveyors.

He continues, I see a huge dichotomy amongsurveyors; some are very well aware and others are not. One surveyor I know ofwalked into a Southern California hospital who knew surveyors in the past hadlooked at firewall penetration above the ceiling. The surveyor said, Idlike to inspect that. They brought in a ladder, opened the tile and thesurveyor wrote them up for not having containment. Its a big issue.

Also at issue is environmental sampling. I dont(advocate) that, Hansen says. If there is an issue of potentialcontamination, I investigate first. If I see some evidence of water intrusion orsomething that could lead to mold, then I say lets mitigate it. Clean it upand then test as a clearance document. If you are remodeling, go into the areasthat abut the construction zone and do your baseline testing. Then during theterm of construction, walk around with your particle counter and see how thatcompares. At determination, when everything is cleaned up, then do clearancetesting. The problem I have with testing is that people say, Im sure itshere; I can see mold, lets test. You have justcreated a negative document. Thats something I learned from my attorneyfriends that you dont want to do. So its better to address it if you havestrong suspicions, if someone has been above the ceiling and you now have issuesbelow the ceiling, or if you had a water or roof leak then lets get allthose things cleaned up, tested and made right. Do some environmental foggingabove the ceiling with a hospital-grade antifungal and then test. The clearancetest is going to be your key to saying everything here is good. In the event the testing shows something, go backand find out why and repeat the test.

Following correct procedure is a learnedbehavior, according to Hansen, and encourages hospitals to educate their workerson infection control issues related to construction and renovation.

Technology can only help those who know how toapply it, Hansen says. They need to know how to use it to reduce theintrusion of environmental pathogens. Its important to get educated aboutpolicies, procedures and ways to remediate construction-related contaminants.Send healthcare professionals to educational seminars so they can learn from theexperts and have the materials they can bring back with them to teach theircolleagues. Education is a slow process, however. Some largehospitals are very aggressive about training while many smaller facilities arent.We need a dissemination of information on a more widespread basis to bringeveryone up to speed.

Hansen says that from an infection control andconvenience factor, he glad that hard surfaces are making a comeback in newconstruction and renovation projects. Carpets are awful. I go head to headwith manufacturers because I dont like carpet in the healthcare environment.If they want to put it in the CEOs office andin administration areas, thats fine, but not in any corridor where a110-pound nurse has to push someone my size on a gurney or there is concernabout the flooring not being easily cleaned.

"The current movement toward antimicrobialproducts has implications for the physical plant that arent obvious,according to Hansen. I think a few of the antimicrobial products are good butoverall they simply provide a nice psychological benefit, Hansen says. Iget a lot of questions about antimicrobial components in filter pads. What weare dealing with in ventilation systems is mold, not bacteria. If you want touse antibacterial soaps and cleaners, thats fine. Where we have found a lotof people touting the antimicrobial component is carpet manufacturers and Iwould prefer not to have it at all. In general I think its overplayed.

The rush to embrace all manner of antimicrobialhand sanitizers and disinfectants also can lead to physical plant-relatedproblems. Hansen recalls a hospital in Southern California where healthcareworkers rinsed their hands and quickly turned off the water. They didntlet the water run long enough to thoroughly wash it down the drain and (theseproducts) form a gel in the sewer. The only way to break through it is withcompressed air because if you run a snake down the drain it punches through thegel like a tubeless tire and the gel is still there. We had a case where thehospital wasnt sure how to use the compressed air and used too much, poppingthe sewer connection and flooding five operating rooms. I think many products inhospitals today need to be looked at carefully.

"Im not a fan of the heavy lanolin-based soapseven though that seems to be the most common. I am a fan of waterlesshand-hygiene stations, despite what the fire marshals say. I like having fewersinks in the hospitals for the simple reason you end up having to oversize thehot water system that leads to the potential for Legionella outbreaks. In comecases, however, sinks are not used enough and the traps dry out and thenyou get the sewer smells. There are a lot of things weve done in hospitalsthat make sense and theres a lot of things that dont make sense.

What does make sense, Hansen adds, is conductingeffective risk identification and management, a program whose cost easilycreates the following returns on investment:

• Reduction in the incidence of airborne cases of nosocomial infections

• Improvements in healthcare worker productivity

• Reduction in workers compensation claims

• Reduction in healthcare worker turnover

• Reduction in patient and employee complaints

• Reduction in HVAC system energy consumption