Pandemic Places Importance of Preventing Environmental Infection at Center Stage

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As the health care setting progresses from focusing primarily on COVID-19 toward living with the disease, infection preventionists (IPs) are also grappling with how to continue a new era of infection prevention. Basic infection prevention principles, which may have been placed on the back burner for 2 or more years, are reemerging. Staff members are now coming to IPs for recommendations in areas where IPs previously may not have had as much oversight.

One subject IPs may start to see as being ideal for more feedback and collaboration involves environmental infection prevention. The role the area around us plays in infection prevention has become more evident throughout the pandemic. As health care systems restart projects that may have been put on hold, these opportunities may now be revisited. Some common environmental areas where IPs can provide valuable input include construction projects, water safety, and ventilation.

Construction Projects

Construction projects in the health care setting greatly increase the possibility of pathogens such as mold and fungus being present in the environment. Organisms such as Aspergillus can be found in environments where construction was or is occurring if proper infection prevention practices are not followed. In healthy individuals, this organism may not cause any harm or even be detected. However, in patients who are immunocompromised, this organism can cause respiratory illness that can be difficult to treat.

The Facility Guidelines Institute (FGI) is an organization that provides guidance around the planning, design, and construction of health care facilities.¹ FGI requires that a tool, the infection control risk assessment (ICRA), be completed before all construction projects begin.

An ICRA organizes a construction project by classifying the type of work that will be occurring along with the level of risk involved should a project not be performed correctly. Depending on how the type of work and risk align, different expectations are listed for how the project should be carried out.

The ICRA document is to be filled out by the project manager of the construction site who will be providing oversight on compliance. Once a draft of the scope of work has been completed, it should be sent to the other key stakeholders such as those in safety and infection prevention. If there are questions on the scope of the project, IPs should feel comfortable asking for a job site walk-through.

Once the project is under way, and especially if there is high risk to surrounding patient care areas, IPs should go around the site weekly to ensure that the ICRA is being followed. Any concerns should be brought to the project manager for immediate rectification.

Water Safety

A water management program in a health care facility is key in mitigating the spread of infections. Common practices in health care systems, from providing oral care to patients to the reprocessing of medical devices, require use of water. If microbial growth is allowed to occur in any of these areas, it can pose a serious risk to patients. Among other organisms, a water management plan aims to mitigate Legionella, a genus of bacteria that can be transmitted to immunocompromised patients if they inhale contaminated water.

The CDC provides resources for better understanding of a facility’s current state regarding water safety. The agency’s guide, “Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings,”² helps explain the steps that should be taken in creating a water management plan.

IPs who may not know much about their facility’s water management plan should reach out to their facilities team to discuss and partner in the creation of a plan. One of the first priorities is to create a diagram of how water enters and leaves the facility. This allows potential hazards such as fountains, stagnant water, and high-risk units to be better identified. With these risks recognized, mitigation strategies can be put in place.

Ventilation

As has been emphasized during the pandemic, proper ventilation can lead to decreased risk of infection. The concept of ventilation as a means of reducing infection transmission risk has been a part of health care expectations since well before COVID-19.

The American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE), along with FGI, helps to provide best practice expectations for health care facilities relating to heating, ventilation, and air conditioning (HVAC) systems.³ Because air circulation is critical to reducing airborne transmission of communicable diseases, ensuring areas are regularly meeting the minimum air exchanges (MAC) for outdoor air is crucial.

In addition to MAC, the use of high efficiency particulate air (HEPA) filters is an added way of trapping particulates that may be present in the air. When deciding what type of HEPA filter to use, it is important to determine whether it has met HEPA classification and to know how often it needs to be replaced.

Because air is circulated through facilities throughout the year, the changing temperature and humidity of the outdoors can affect the HVAC system indoors. To curb the potential for microbial growth, it is important to review temperature and humidity standards as provided by ASHRAE and FGI for each area, to monitor regularly, and to know what to do if levels get out of range.

Conclusion

The risk of infection transmission in construction projects, water safety, and ventilation all reflect how these projects require multidisciplinary oversight. Professionals from environmental health and safety, facilities, infection prevention, and more must work to ensure that when changes are made to a facility, patient safety is kept at the forefront. Similarly, even during periods of stagnation, it is also important to review current workflows to ensure no additional changes need to be made.

References

1. Guidelines for Design and Construction of Hospitals. Facility Guidelines Institute. 2018. Accessed February 10, 2022. https://fgiguidelines.org/guidelines/2018-fgi-guidelines/
2. Developing a water management program to reduce Legionella growth & spread in buildings: a practical guide to implementing industry standards. CDC. June 24, 2021. Accessed February 10, 2022. https://www.cdc.gov/legionella/downloads/toolkit.pdf
3. ASHRAE offers course on the role of HVAC systems on infection control. News release. American Society of Heating, Refrigerating and Air-Conditioning Engineers. March 23, 2020. Accessed February 10, 2022. https://www.ashrae.org/about/news/2020/ashrae-offers-course-on-the-role-of-hvac-systems-on-infection-control