The Healthcare Architect’s Role in Infection Control Risk Assessment
Many hospitals are undergoing some form of expansion, renovation or construction to respond to changes in healthcare delivery, emerging technology or demographics. At the same time, regulatory focus on the reduction of hospital-acquired infections has increased the importance of a well-developed infection control risk assessment (ICRA) process related to construction and renovation. The healthcare architect must be aware of the potential risks and exposures caused by construction activities and must know and understand the ICRA process. By participating in this process in an advisory capacity, the architect can help healthcare clients develop strategies for ensuring patient safety.
Hidden Dangers of Construction
The most common microbes associated with demolition and construction are Aspergillus, a fungus found in dust, soil, moisture and mold, and Legionella, a bacteria found in water. They can be harmful, even deadly, to patients with compromised immune systems. Certain patients, such as the critically ill, neonates, and those receiving chemotherapy and dialysis, are greatest risk from construction dust and debris.
Also, care delivery locations, such as the operating room, must be especially protected from the contamination since they are maintained as a sterile environment. The ICRA process identifies and measure potential risks based on the type, location and duration of construction and the affected patient population or patient care activity. Plans for preventive measures, barriers, monitoring and cleaning are implemented to minimize exposure.
The Presconstruction ICRA Process
The best ICRA process is a collaborative one. Before construction has begun, the client will conduct a multidisciplinary committee meeting, which includes the hospital’s project manager, infection control practitioner, representatives from affected hospital departments, the architect and the contractor. Hospital policies and architectural plans are reviewed. With the architect lending expertise and advice, construction phases are planned, locations and types of barriers are determined, and the route and disposition of construction debris are approved. Air sampling and compliance monitoring are planned. Cleaning responsibilities, procedures and schedules are specified. (In addition to a primary construction site, ICRA must be determined for any mockup rooms planned within a patient care area.)
Examples of ICRA Activities
- Dust and debris from drilling, cutting, removing walls, ceiling tiles and floor coverings must be contained by sealed plastic and drywall barriers. - Negative air pressure must be maintained within some construction areas to prevent the migration of dust. - HVAC systems must be isolated and sealed to prevent them from spreaking dust into patient areas. New ductwork should be capped during storage and transport so it does not collect dust before it is installed. - Construction debris must be transported in covered carts and disposed of in a designated area away from air intakes. - External excavation must be scheduled and planned carefully since it can release fungus into air-handling systems. - Water systems that have been shut down during construction should be flushed and decontaminated before they are returned to service since they can contain stagnant water or scale that has been loosened by drilling vibration. - Cleaning of the worksite, testing and inspection must be performed so the area and its systems can be determined as safe for patient use.
ICRA Consideration During Master Planning
In the master planning process, clients often request the design of a “shelled” area for future expansion or an area that will be contiguous to an existing space. When creating and presenting design alternatives, the architect should consider and address ICRA concerns since the clients may want construction or fit-out of the new space while adjacent clinical areas are functioning. Considerations of ICRA impact can affect the selection of a particular design, i.e., “Which design alternative will enable this expansion to take place with the least infection risk to patients, the least disruption in daily operations due to ICRA activities, and the least impact to the project budget?” Project budgets are another good reason to consider ICRA early in the design process. Barriers, testing and other ICRA activities will surely add to the costs.
Regulations and Recommendations
A hospital’s ICRA policy, process, and practice are reviewed as part of compliance with the Joint Commission on Accreditation of Healthcare Organizations infection control and management of the environment of care standards. Association of Professionals in Infection Control and Epidemiology and the Centers for Disease Control and Prevention have published guidelines for infection control during construction, with recommendations extended to other healthcare settings such as long-term care and ambulatory surgery centers. American Institute of Architects references ICRA in Section 5.1 of the 2001 edition of its Guidelines for Design and Construction of Hospital and Healthcare Facilities with instructions to “incorporate the specific, construction-related requirements of the ICRA in the contract departments.”
Although not every Department of Health requires ICRA on architectural plans, state regulatory agencies will sometimes the ICRA status of a project.
Today’s healthcare clients expect more support from their architects. From strategic planning through the official opening of a new unit or building, design professionals must be able to function in an advisory capacity extending beyond pure design issues into functionality and quality of care. A thorough knowledge of ICRA will enhance an architect’s ability to become a more valuable resource.