The importance of containing contaminants during a health care-related construction project has recently become better understood by the design and construction industry.
Over the course of the past several years, the AIA (American Institute of Architects), CDC (Centers for Disease Control), and JCAHO (Joint Commission for Accreditation of Health Care Organizations) have all published guidelines to assist owners, design professionals, and contractors in preventing the spread of contaminants during construction-related activities.
The emphasis of this article is the role the design professional plays in assisting the owner and the contractor in managing a safe air quality environment during a construction project in a hospital or other health care facility. Design and construction of hospitals present many unique challenges, and the complexity of maintaining a safe environment is certainly one of the most difficult. The safety issues become even more evident when you consider that nearly 75% of all construction projects in health care involve an expansion or renovation to an existing hospital structure.
Defining the Infection Control Risk Assessment (ICRA)The Infection Control Risk Assessment (ICRA) was first introduced as a requirement for patient areas affected by construction projects in the 2001 edition of the AIA Guidelines for Design and Construction of Health Care Facilities. This requirement was then referenced and made mandatory by the JCAHO in the Environment of Care Standard EC 1.7. The ICRA can best be described as a strategic plan that identifies and mitigates the potential risks for transmission of disease-carrying agents that can be transported or spread during a construction project.
The process for developing the ICRA ideally starts at the early design and planning stages of a project. The owner of the facility is responsible for assembling a panel with expertise in the areas of infection control, risk management, facility design, safety, epidemiology, ventilation, and construction. The panel will then address the impact the particular construction project will have on the patient population. The ICRA panel has additional responsibilities for determining the required number of airborne infectious isolation rooms, protective environment rooms, handwashing facilities, and other design-related issues that are not specifically addressed in this article. The following is a list of issues the ICRA should specifically address as they relate to construction activities in the facility:
- Impact of disrupting essential services to patients and staff;
- Patient placement or relocation;
- Measures to protect patients and staff from transmission of contaminants during the construction or renovation project;
- Measures to maintain acceptable levels of IAQ throughout the facility during the project;
- Infectious containment; and
- Environmental monitoring.
The plan that is adopted by the ICRA panel is meant to be a living document that should be updated through each phase of the project. During the actual construction, the panel should meet on a regular basis to update the ICRA and to assess the risk as construction progresses. It would come as no surprise to anyone that has been involved in a health care-related construction project that the success of the project depends on many knowledgeable people with expertise from a diverse number of professions. The same multidisciplinary approach is required to ensure the success of the infection control plan for construction projects.
Roles and ResponsibilitiesThe role of the consulting engineer in assisting in the development of the ICRA has become increasingly more important as the scope and complexity of the guidelines for contaminant control have evolved. The complexity of design and construction of health care buildings has placed a great deal of pressure on the design professional to be an expert in many areas. Infection control is one of the areas where owners have an expectation that the design team will provide the ICRA as a part of basic design services.
In many cases, the representatives from the health care facility do not understand that the design professional does not have the expertise to lead an ICRA, is generally not compensated for this service under the basic design services agreement, and may not carry insurance to perform the service. The role of the design professional is an important one as an advisor, and it is certainly recommended that the design architect and engineer be involved in the process to assist in their particular area of expertise.
The HVAC design engineer can play a very important role in the development of the phasing and pressure control aspects of the ICRA. In many cases, there is no one on the design and construction team who understands the existing and proposed HVAC systems, pressure relationship issues, principles of air movement, and potential construction phasing implications better than this individual.
The education of the ICRA panel on fundamental HVAC design concepts and code requirements is often overlooked as other, more visible issues, such as construction barriers, are discussed at length. The design engineer should communicate how the HVAC system is intended to function once construction is complete, what capabilities the system has for maintaining pressure control, and how the system will operate during the various phases of construction. Communicating this information will help to guide the ICRA panel and assist in avoiding costly assumptions about the HVAC systems.
The AIA Guidelines are specific in stating, "the design professional shall incorporate the specific, construction-related requirements of the ICRA into the contract documents." The final responsibility for the development of the ICRA clearly rests with the owner of the facility. The logic for this requirement is obvious when you consider the fact that the medical staff at the facility in question are most familiar with the types of patients and procedures performed. It is incumbent on the design professional to educate the owner of the need for the ICRA to be in place early in the design process in order to ensure that the design is integrated with the infection control strategy.
Clean to DirtyAirborne Contaminant Control: The single most important measure to avoid the spread of airborne contaminants from the construction area is to ensure the construction area remains under a negative pressure. The ICRA should address which areas will be affected by the construction and to what extent. Any major renovation project will most likely require the construction area to be sealed from the remainder of the facility and maintained at a negative pressure relative to adjacent areas. The method of maintaining negative pressure, sizing of equipment, and monitoring of the construction area are the responsibility of the contractor. However, the design engineer must provide a design that allows the contractor the ability to construct the project without compromising patient, staff, and worker safety.
A construction project involving a renovation that has multiple phases is probably the most difficult type of project for an HVAC engineer to effectively design when working in a health care facility. Architectural considerations generally end at departmental boundaries, where HVAC systems may supply air to many areas that are unaffected by the architectural scope of work. Diligent investigation and understanding of how the entire HVAC system operates is critical to developing a design that does not compromise areas of the facility that are still providing patient care.
Use of Air Delivery Systems During ConstructionAn area of major concern during a construction project is the use of the air delivery systems to condition the space prior to owner final acceptance and occupancy. The use of the AHUs, supply ductwork, and return ductwork for temporary heat and dehumidification is fairly common practice for most major construction projects. The use of such equipment during construction may have serious consequences if strict policies are not in place.
The ICRA should address what equipment will be used for temporary heat and humidity control and what conditions should be placed on air delivery systems. Air delivery systems that will eventually serve the high and highest risk areas of the hospital should not be used under any circumstance until all major construction-related activities are complete and the space is substantially complete.
The limitations on the use of AHUs and duct systems serving each area of the hospital affected by the construction should be reviewed with the ICRA panel. The contract documents should specifically indicate the permanent air systems that may be used for temporary heat and dehumidification purposes. In the event that the permanent air delivery systems are to be used, the filtration level should not be compromised under any condition for the duration of the construction project.
Many infection control professionals have described the ductwork systems in a hospital as the "pathway for pathogens." Therefore, special protection of the ductwork systems during installation should be carefully reviewed when performing work in a health care facility. Sheet metal sections should arrive at the construction site with protective covers at each end. The covers should only be removed for installation, and the interior of each section should be wiped clean after each section is installed. Open ends of ductwork, supply diffusers, and return registers should be covered for the duration of the project to ensure that the interior of the ductwork is not compromised with contaminants.
These recommendations may seem like common sense; however, when they are integrated into an aggressive construction schedule with extreme budget pressures, they will many times be omitted to save time, money, or both.
Costs of Construction-Related Infection Control ManagementThe health care system struggles to maintain tight cost controls in the face of lower reimbursements from the federal government and insurance companies. At the same time these pressures are reducing the overall capital that is available, the patient population is demanding more services with better amenities. Additional challenges of attracting qualified doctors and nurses along with the need to keep pace with new medical technologies are leaving health care providers no choice but to continue to renovate and expand. The financial pressures are further amplified by the additional regulatory requirements that add cost to any health care construction project.
The cost of properly conducting construction to avoid spreading contaminants can be significant. The impact can be minimized with proper planning and education at the early stages of a project. Projects that do not address these issues early in the planning phase may face costly changes and potential project delays. Over the past several months, several clients have been forced to make changes to designs and revise schedules to meet the more stringent requirements.
A project currently under construction was forced to alter a steam pipe routing from being installed above the ceiling of an occupied patient floor to the roof. The changes were made to avoid the extensive ICRA requirements and disruption to the staff and patients in the area of the installation. The additional cost of installing the added steam piping was determined to be a better solution due to the reduction of risk and disruption. The design of the steam pipe routing had been agreed upon months before the project began; however, the extent of the disruption was not fully understood by the owner, and a change was necessary.
An example of a more significant change to a project was the decision by an acute care hospital to abandon plans to renovate an existing operating suite. The ICRA panel was involved early in the design and when the requirements for infection control were fully understood, a decision to build a new operating suite was determined to be a better solution than trying to renovate the existing suite. Determining the total costs associated regarding each project is essential to making a good decision. As everyone involved with construction in health care becomes informed regarding the requirements associated with mitigating the spread of contaminants, they will likely begin the process early and avoid the unexpected costs and delays of implementing infection control measures after the design is complete.
ConclusionThe concerns over mitigating the risk of spreading contaminants during a construction project at a health care facility continue to evolve. The regulatory requirements are expanding, and the governmental bodies responsible for approving the plans for proposed construction are more aware than ever before of the necessity to have a workable ICRA in place prior to beginning any work. The design profession should be taking a leading role in the education of owners on the need to follow this prudent approach to avoiding the spread of infection during construction.
The number of patients who die from infections they contract while at the hospital has been reported to be as high as 90,000 per year. One cause of contracting these infections is known to be from contaminants spread during construction projects. The AIA, CDC, and JCAHO requirements are in place to help reduce the number of infections contracted. The design professionals, owners, contractors, and regulatory agencies involved in health care construction are the individuals responsible for understanding, executing, and enforcing the infection control measures required to reduce the infection rates. The result of these efforts will be a safer environment for the patients and staff who are treated and work in our health care system. ES
TRO/The Ritchie Organization is a 225-person planning and design firm specializing in health care, academic, and corporate/commercial facilities. Services include programming/feasibility studies, architecture, planning, interior design, and engineering. Based in Boston, the firm maintains regional offices in Birmingham, Sarasota, and Memphis. For more information visit www.troarch.com.