Infection Control and Prevention during Construction

Infection Control and prevention during Construction

By: Paul Gentile, Shalom Patel, Siyeh Gretzinger and Aaron Milloy

Environment of Care is a fundamental domain of the infection prevention scope of practice. Infection prevention programs are responsible for recognizing and monitoring the elements of a safe environment including assessing and reducing the infection risks of design, construction and renovation that impact healthcare settings. Infection Preventionists are utilized as consultants, collaborators, and enforcers to provide best practice guidelines and recommendations to ensure quality and safety within a clinical setting during these projects. Industrial hygienists can also serve in a similar capacity in regards to construction inside and outside of healthcare. Developing a team of key stakeholders including Infection Preventionists, industrial hygienists, safety officers, engineers, architects, project managers, contractors, and construction workers lays the foundation for a successful blueprint.

Pre-Construction

Prior to the start of any construction project, no matter the size and scope, it is important to incorporate infection prevention standards and, where possible, consult with Infection Preventionists or Industrial Hygienists to identify the potential infection risks during and after construction. Conducting a pre-risk assessment is an important step not only in the healthcare industry, but any setting where individuals are present during and after project completion. This assessment provides support structures that identify infection control, air quality, utility requirements, noise, vibration and any other hazards applicable to create an environment of care that promotes prevention and control of airborne and waterborne contaminants. This is necessary because microorganisms dispersed during construction projects have been documented to cause infections. Dust contamination, and potential dispersal of fungal spores, from construction and renovation projects, account for approximately half of all healthcare-associated Aspergillus outbreaks (1). Water distribution systems are also an essential part of the environment of care, and any project affecting these systems should establish proper precautions, as bacterial and fungal contaminants have been found in drinking water as well as aerosolized from construction activities (2).

An essential next step in the planning process is an Infection Control Risk Assessment (ICRA). This is an important method for assessing and preventing all hazardous risks to those who will be in the vicinity of the construction project (3). Following this risk assessment various interventions and monitoring programs can be developed and put into practice to continuously prevent and assess the airborne and waterborne hazardous risks while the construction project is taking place. Interventions can include containment barriers, personal protective equipment, air filtration, negative airflow ventilation, and debris removal (3). Use of an ICRA is beneficial in the assessment of the type of interventions necessary for a project. Another significant component prior to construction and renovation, is the design planned for the space(s) being completed. How the space is designed, the materials used, as well as the type of air and water systems, are all relevant parts of preventing infections in individuals that inhabit the space after it is built. Studies have shown building-associated infections have been attributed to the design and maintenance of heating, ventilation, and air conditioning (HVAC) and water systems (2, 4). Other features such as the characteristics of wall surfaces and ceiling tiles, type of flooring, sink and faucet design, as well as the placement of hand hygiene soap and sanitizer dispensers are all important parts of the design process that can help prevent infections (3).

Mid-Construction

During the mid-construction phase, it’s important to continue to monitor for any risks that could potentially compromise the environment. As part of the development of the ICRA, risk mitigation strategies should have already been discussed to prevent the spread of any waterborne and airborne biological contaminants. Depending on the length of the construction projects, contractors will work with the Infection Preventionist and construction team to develop a timeline based off of a phased approach. During this period, modifications may be made to contractor requisites and to the ICRA created during the pre-construction phase.

Requirements for long-term construction projects will entail constant evaluation of the area to ensure safety standards continue to be met. Barriers will consist of more rigid material such as a hard plastic or sheetrock. Contractors should also make sure that the barriers are sealed and intact to prevent dust and contaminants from escaping the work site. Food and drinks should not be at the construction site as they increase the risk for insects and pests and exposure to potentially hazardous substances (i.e. chemicals) that are being used. Standard wet or sticky walk-off mats should be applied at construction entrances and exits to reduce the spread of dust and debris. These mats should be changed daily or when the mats are no longer able to capture dust and debris.

Depending on the ICRA matrix, contractors may also be required to wear certain personal protective gear such as a coverall and shoe/ hair covers while working in specific areas. For construction projects being performed in high risk areas, personal protective equipment (PPE) will be important to prevent the spread of any biological/ airborne contaminants. Contractors should also have clean PPE readily available on site to prevent re-use of contaminated PPE.

For ventilation purposes, a high-efficiency particulate absorbing (HEPA) filter or an air scrubber may be used depending on the ICRA classification of the construction project. These pieces of equipment

should be checked on a daily basis while construction is ongoing. Filters should also be changed when there has been accumulation of dust/debris noted. To ensure that the filters and HEPA machines are working appropriately, the contractors should also have a way to measure that negative airflow is being maintained at the project site. The best alternative to monitoring this is to have a manometer reader, which can tell an individual if the negative pressure is being maintained according to safety standards. This will ensure that dust/ debris is not blowing out of the construction site to adjacent areas. In addition to making sure negative air flow is being maintained, ceiling tiles should always be in place when not in use.

Lastly, in terms of water management and plumbing, many construction sites may have existing piping that is not being used. If the project is going to be long-term/prolonged, it is vital to flush the pipes per the facilities water management policy to prevent the spread of Legionella and mold [7]. If the facility has a water management engineer on site, Infection Prevention, the industrial hygienist, or contractor will discuss mitigation solutions to prevent the spread of waterborne contaminants while the construction is ongoing.

Post Construction

Upon completion of the construction phase, the area will need to be reviewed, cleaned and prepared for occupancy. Teams involved during the project including but not limited to: contractors, environmental services, and facilities management, should all participate in completing the final steps.

The first step following completion of the project should be conducting a walk-through with the key stakeholders [5, 6]. This will serve as a final inspection to ensure the project has been completed in accordance with all federal, state, and local regulations [5]. Contractors should be responsible for cleaning up dust and debris, as well as any tools and equipment used during the construction. Any barrier walls will need to be removed and the area disinfected [5]. Water lines should be flushed to expel any leftover debris and sediment accumulated during the construction phase [5]. In addition, the HVAC system should be tested prior to occupying the building to ensure proper functionality [5]. During this test, vents and ductwork should be thoroughly cleaned to remove leftover waste product [5]. All newly installed furniture and equipment should be evaluated and deemed safe. Fire extinguishers, smoke detectors, and any additional electrical equipment should also be tested to ensure proper functionality [5]. As a concluding step, environmental services personnel should perform a terminal deep-clean prior to occupying the new space [5, 6].

Conclusion

The role of infection prevention in construction and renovation projects allows for multidisciplinary collaboration and improved understanding of the relationship between the environment and infection by all parties involved. This helps ensure safety standards are being followed and minimizes the overall risk of infection for future occupants.

1. Kanamori, H., Rutala, W.A., Sickbert-Bennett, E.E., Weber, D.J. (2015). Review of Fungal Outbreaks and Infection Prevention in Healthcare Settings During Construction and Renovation. Clinical Infectious Diseases, Volume 61(3). P433–444. https://doi.org/10.1093/cid/civ297

2. Bartley, J., Olmsted, R. (2009). Water Systems Issues and Prevention of Waterborne Infectious Diseases in Healthcare Facilities. In Boston K.M., et al, eds. APIC Text.

3. Bartley, J., Olmsted, R. (2009). Construction and Renovation. In Boston K.M., et al, eds. APIC Text.

4. Bartley, J., Olmsted, R. (2009). Heating, Ventilation, and Air Conditioning. In Boston K.M., et al, eds. APIC Text.APIC Text of Infection Control and Epidemiology. 3rd ed. Washington DC: Association for Professionals in Infection Control and Epidemiology, 2009. pp.106-5.

5. Moore, B., 2015. The Infection Preventionist’s Role in Construction and Renovation: Before, During and After. [online] Infection Control Today. Available at: <https://www.infectioncontroltoday.com/view/infectionpreventionists-role-construction-and-renovation-during-and-after> [Accessed 19 August 2021].

6. Jointcommission.org. 2021. Infection Control Considerations in Construction Projects. [online] Available at: <https://www.jointcommission. org/resources/news-and-multimedia/blogs/on-infection-preventioncontrol/2019/10/infection-control-considerations-in-construction-projects/> [Accessed 19 August 2021].

7. “Reopening Buildings after Prolonged Shutdown or Reduced Operation.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 22 July 2021, www.cdc.gov/nceh/ehs/water/legionella/buildingwater-system.html.

About the Authors

Paul Gentile, is the 2021 Greater Atlanta APIC Chapter 25 Board Secretary and Sr. Infection Preventionist for Emory University Hospital Midtown in Atlanta, Georgia. He has over 16 years of clinical experience in healthcare and over 5 years of experience working in the Infection Prevention field. He has research focusing in areas of Public Health, Behavioral/Clinical Psychology, and Ophthalmology.

Shalom Patel, is the 2021 Greater Atlanta APIC Chapter 25 President and Infection Prevention Manager for Piedmont Healthcare in Georgia. She has over 14 years of experience in healthcare including 9 years as an Infection Preventionist. Shalom worked in public health at the local, state, and federal level prior to joining Piedmont. She has an educational background is in health sciences and epidemiology.

Siyeh Gretzinger is an Epidemiology MPH graduate from Emory University who works as an Infection Preventionist at Emory University Hospital Midtown. In her role, she works with her team to mitigate the effects of COVID-19 and reduce the risk of hospital-acquired infections. Previously, Siyeh worked conducting epidemiological research, developing and evaluating statistical models, and implementing quality improvement interventions to enhance patient care in the outpatient setting.

Aaron Milloy is an MPH graduate from Emory University Rollins School of Public Health. He currently works as an Infection Preventionist at Emory University Hospital Midtown in Atlanta, Georgia. Currently he is the Infection Prevention lead for the facility’s Clostridium difficile hospital acquired infection initiative.