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Infection Control Risk Assessment - ICRA 101
THE MISSION
Provide the health care facility with the
best trained, knowledgeable and qualified
construction workforce in order to get the
job done right and protect the health and
safety of patients, staff, workers and the
public with minimal disruption of daily
activities and operations.
THE CHALLENGE
Hospital associated infections (HAIs) like MRSA and
aspergillus continue to be a problem in health care facilities.
It is estimated that each year in the US:
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1.7 million patients acquire HAIs
99,000 patients die from these infections
5,000 HAI deaths are from construction related activities
Studies indicate invasive aspergillosis can occur during
construction and renovation
OBJECTIVES
• Describe the various risks and challenges involved in working in
occupied health care facilities
• Explain how to develop a health and safety plan between the
facility owner and contractor
• Identify different effective procedures to protect patients, staff,
workers, and the public from any hazardous materials,
contaminants or infectious agents
• Recognize and understand the remediation of hazardous
materials, contaminants or infectious agents
• Differentiate the responsibilities of the contractor, architects, and
facility owner
HEALTH CARE FACILITIES
• The primary goal is to maintain the patients’ health
• Patients are vulnerable to infections and diseases due to
weakened immune systems
• Immunocompromised patients include burns, premature
babies, organ & bone marrow transplant, ventilator, dialysis
• Daily operation of facility is critical
• Protect PATIENTS, staff, workers and the public
HAZARDOUS MATERIALS
When working with or around hazardous materials it is
essential to warn others of the possible dangers using:
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Placards
Labels
Containers
MSDS
HAZARDOUS MATERIALS
• Materials that pose risk to: health, safety, and the
environment
• Present at jobsites within health care facilities in many
different forms
• Acute and chronic health effects can result from exposures
over OSHA’s PEL
HAZARDOUS MATERIALS
• Materials that pose risk to: health, safety, and the environment
• Present at jobsites within health care facilities in many different
forms
• Acute and chronic health effects can result from exposures over
OSHA’s PEL
• Permissible Exposure Levels – What is your level?
• What are some Hazardous Materials you see at work?
HAZARDOUS SUBSTANCES
Hazards found in occupied building:
• Asbestos
• Lead
• Fungi
• Silica
• Chemicals
HAZARDOUS SUBSTANCES
Hazards found in occupied buildings:
• Bacteria
• Mold
• Radiation
• Mercury
• Medical Waste
I.L.S.M. TEAM
• Interim Life Safety Measures (ILSM) team’s goal is to ensure
safety of patients
• Implements emergency evacuation plans and identifies fire,
safety, and security measures
• Must have and maintain an unimpeded exit plan. If
construction work blocks the exit plan, the ILSM team must
have an alternate plan
• PATIENT safety must come first
I.C.R.A. TEAM
• Infection Control Risk Assessment (ICRA) team’s goal is to
minimize risk of hospital acquired infections (secondary
infections)
• Studies scope of work to be done and evaluates risk factors
and potential hazards
• Matrix: Matches project type and patient risk group
to determine work area classification
• ICRA forms – required by The Joint Commission (TJC)
CONSTRUCTION PROCEDURES
• Classification determines the type of barriers
• Can change if mold, lead or asbestos are found
• Air tight seals are essential
Portable cubes
Soft walls
Hard walls
Anterooms
Positive and/or negative air pressures
PORTABLE ISOLATION CUBE
• Small single person containment
used for inspection or short term
• Collapsible barrier that can be
easily maneuvered and deployed
• Great for working above ceilings
• Negative HEPA air seal and vacuum
cleaner
• What is the estimated total cost of
all the items in this picture?
SOFT WALL SYSTEM
• Quick and safe
• Suitable for short term
• Convenient for emergencies
• Zipper door for access
• Will this work with negative
and/or positive air pressure?
HARD WALL SYSTEM
• Long term temporary partition
• Protects patients and the public
from contaminants
• Built with common construction
materials like metal studs and
drywall
• Sealing is essential
• Sustains impacts from gurneys
ANTEROOM
• Changing room for PPA
• Extra protection in
sensitive areas
• May be hard or soft wall
systems
• Excellent transition
between differential air
pressures
AIR PRESSURE
• Positive
• Negative
• Equal
• Monitoring:
 Flutter gauge
 Ball gauge
 Magnehelic
• Documentation - using data
from an air particulate counter
PERSONAL PROTECTION
• Personal protection equipment
(PPE) is worn inside contaminated
and protects workers from hazards
or contaminated material
• PPE is donned prior to entering
contaminated area and removed
prior to entering patient occupied
area
• What is PPA?
PATIENT PROTECTION
APPAREL
• Protective apparel designed to
prevent transferring of
contaminants from worker to
patients
• Used when entering or exiting
the containment area
WORKSITE PREPARATION
• Before construction work commences existing finishes must
be protected
• Fixtures, furniture, floors, computers, walls, floors, doors,
windows, window treatments, casework and contents,
elevator cabs and all equipment
• Protective materials – polyethylene sheeting, hardboard,
plywood, cardboard, tape and self sticking floor protector
• Decommission any equipment or computers in cooperation
with hospital staff.
• Patient privacy must be protected at all times, ie.. charts
JOB COMPLETION
• Obtain inspection documents
• Jobsite cleaned and disinfected by contractor and the
hospitals environmental services team
• Fire alarms and smoke detectors tested
• HVAC systems functioning properly
• Remove barriers and signs
• Final cleaning performed by the facility
WORKER TRAINING
• UBC members get a 24 hour class that includes classroom and
“hands on” shop activities
• 8 hour Trades Awareness class available to everyone
• AIA continuing education class – 1 ½ hour lunch and learn
• Look at the shop picture, see anything wrong or concerning?
WORKING TOGETHER
AWARENESS – COMMUNICATION - PROTOCOL
• To minimize risks of secondary infection and other issues,
contractors and workers must understand procedures of
working in an occupied health care facility (29 CFR 1926,
OSHA, NYC Guidelines for mold remediation)
• Knowledgeable facility managers and employees will help
reduce risk of secondary infections (CDC, TJC, CMS, ASHE)
• Architects recognize the risks and protocol involved and
inform contractors and facility managers of specific
precautions. Recognize the importance of a highly trained
workforce. (FGI - 2010 edition)
Infection Control Risk Assessment - ICRA 101
• The United Brotherhood of Carpenters and Joiners of America is a
Registered Provider with The American Institute of Architects Continuing
Education Systems (AIA/CES) for AIA members. Certificates of
Completion for both AIA members and non-AIA members are available
upon request.
• This program is registered with the AIA/CES for continuing professional
education. As such, it does not include content that may be deemed or
construed to be an approval or endorsement by the AIA of any material of
construction or any method or manner of handling, using, distributing, or
dealing in any material or product.
• Questions related to specific materials, methods, and services will be
addressed at the conclusion of this presentation
Construction ICRA:
Best Practices in Healthcare Construction
The Carpenters International Training Fund responded by creating:
Construction ICRA:
Best Practices
in Health Care
Construction
in Occupied
Facilities
Training and Qualification Program
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Construction ICRA:
Best Practices in Healthcare Construction
Training Program Goals
• Develop comprehensive skill-sets to
address the concerns of health care
administrators for containing pathogens,
protecting patients, and working without
disrupting operations
• Heighten the sense of accountability and
responsibility by those working in occupied
facilities
• Create a workforce for all levels of the
project: From apprentices and journeymen,
to foremen and superintendents
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Construction ICRA:
Best Practices in Healthcare Construction
Developing Core Training Protocols
• Consulted with industry experts in pathogen
containment during construction work in
occupied facilities to collect relevant,
up-to-date technical material
• Researched which best practices would
deliver the trained professionals that a
health care jobsite requires
• Established a system for the ongoing review
of all training materials with industry experts
to refine technical information and anticipate
emerging job site requirements
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Construction ICRA:
Best Practices in Healthcare Construction
Training Delivery
Tier 1: Train-the-Trainer
Prerequisite: CITF Master Instructor Status
Parameters:
• 40-hours of hands-on training in
simulated conditions at the CITC
• Frequent refresher courses are required
• Qualification certificates issued by CITF
• Re-certification mandatory every
48 months
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Construction ICRA:
Best Practices in Healthcare Construction
Training Delivery
Tier 1: Train-the-Trainer:
Topics focus on awareness and best practices in:
• Blood-Borne Pathogens
• Site-Specific Considerations
• Hazmat Material Overview
• Work Practices
• Recognizing Hazardous Material
• Health Care Facility Awareness
• Lead, Asbestos, Silica and Mold
• Individual Responsibilities
• Controlling Exposure
• Regulatory Agencies and
Organizations
• Exposure Limits
• Routes of Entry
• Health Effects
• Risk Evaluation
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Construction ICRA:
Best Practices in Healthcare Construction
Training Delivery
Tier 1: Train-the-Trainer:
Instruction also covers…
• Documentation
• Work Area Classifications
• Contaminants and Infectious
Agents
• Mold in a Health Care Facility
• Controlling Contaminants
• Pre-Remediation Activities and
Considerations
• Air Pressure
• Personal Protection
• Containing the Work Area
• Remediation
• Pre-work Activities
Work Activities
• Work Practices for Mold
Remediation
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Construction ICRA:
Best Practices in Healthcare Construction
Training Delivery
Tier 2: UBC member training
• 24 HOURS of TOTAL TRAINING
(16 hrs. of class time/8 hrs. hands on)
• Training spans all levels needed on a health care jobsite
- Apprentices
- Journeymen
- Foremen
- Superintendents
• Qualification cards earned:
• Best Practices in Health Care Construction
• Refresher & ongoing training courses required
• Re-certification mandatory every 4 years
• Blood Borne Pathogens Card
• Re-certification available every year
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Construction ICRA:
Best Practices in Healthcare Construction
Training Delivery
Tier 2: UBC member training
Protocol and skill development addresses:
• Hazardous Materials Awareness
• Lead, Asbestos, Silica, and Mold
• Individual Responsibilities to Patients
• The Structure of the ICRA Form
• Regulatory Agencies and Organizations
• How to Deal with Hospital Personnel
• Containing the Work Area
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Construction ICRA:
Best Practices in Healthcare Construction
Training Delivery
Tier 2: UBC member training
Protocols and skill development addresses:
• Work Area Classifications
• Anteroom Construction
• Erecting and Sealing a Soft Wall
• Working Within a Portable Isolation Cube
• How to Establish a Negative Pressure
Environment
• Personal Protective Equipment Familiarization
• How Secondary Infections are Acquired
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The ICRA form is broken down into steps
Step 1: Project Type
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Step 2: Patient Risk Group
The four types of Patient Risk
Groups are:
 Low Risk Group
 Medium Risk Group
 High Risk Group
 Highest Risk Group
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Step 3: ICRA Matrix
The ICRA matrix is the graph used to match project type and
patient risk to determine work area classification I, II, III, or IV.
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Step 4: Surrounding Project Area
Potential impact to rooms surrounding the project area is assessed.
The patient risk group above, below, and around the project area is
determined.
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Step 5: Identify Specific Site
The specific site is recorded: patient
room, clean utility room, medication
room, or other.
Step 6: Related Issues
All issues related to facility systems
such as ventilation, plumbing, and
electrical.
The probability of system outages is
indicated.
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Step 7: Containment Measures
 Are containment measures needed?
 If so, is a soft or hard wall barrier needed?
 Is HEPA filtration required?
Step 8: Potential Risk of Water Damage
Information is determined and recorded, such as:
potential risk of water damage
information concerning structural members and
sprinkler or plumbing pipes to be removed or
altered
Any potential risk of compromising structural
integrity is determined.
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Step 9: Work Hours
The actual time the work will be performed is recorded:
 Will it be done during nonpatient hours?
 Will it be done in segments?
Steps 10–13: Facility Design
 building codes
 Americans with Disabilities Act (ADA)
 American Institute of Architects® guidelines (AIA)
Step 14: Placement of Containment
Barrier placement is determined by:
 traffic patterns, debris removal
 housekeeping needs, fire codes
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Infection Control Construction Permit
 completed and issued by the ICRA team
 issued only for a Class III or Class IV project per the TJC
Changes in Work Classification
The classification level can change during the course of the
project.
 Changes may occur due to processes that create dust or
due to the discovery of mold or other hazardous material
in the containment area.
 If there are any hazardous materials discovered on the
jobsite, the supervisory staff must be notified immediately.
 Communication is essential for the success and safety of
projects.
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Construction ICRA:
Best Practices in Healthcare Construction
How Can We Help You?
• We aren’t looking to re-write
your hospital’s protocol; we
simply want to work
collectively ensuring the
patients safety remains the
#1 Priority!
• Use the resources that are
available to you right now
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Construction ICRA:
Best Practices in Healthcare Construction
8 hour awareness for other
trades or maintenance
• Can your maintenance personnel use some
brushing up?
• Educate hospital staff, RN’s, and FM’s on the
basics of Construction ICRA
• What do insurance carriers think about Continuing
Education?
• Remember, this training can be tailored to
fit your Hospital’s needs
*Worker training is a critical component
of a multifaceted approach to Infection
Control*
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Construction ICRA:
Best Practices in Healthcare Construction
8 HOUR OVERVIEW
• Gain a better understanding of infection control in an
occupied facility
• Adhere to all work class precautions
• Have the ability to recognize hazards
• Basic understanding of barriers, HEPA machines,
air changes, regulatory agencies, finding mold, etc.
• Have the ability to recognize hazards
• Understand their responsibilities during emergency
situations
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Construction ICRA:
Best Practices in Healthcare Construction
How Can You Help Yourselves?
*You have the resources available NOW
to implement the Construction ICRA
Qualification in your Facilities*
*Put language in your Pre-bid Docs,
Hospital Spec Docs, and Construction
Docs.*
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Construction ICRA:
Best Practices in Healthcare Construction
How Can You Help Yourselves?
**REQUIRE OR MANDATE ALL
CARPENTERS WHO WORK IN
YOUR FACILITY SHOW PROOF
THEY HAVE TAKEN THE UBC 24
HOUR CONSTRUCTION ICRA
TRAINING**
Both stickers and qualification cards
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Construction ICRA:
Best Practices in Healthcare Construction
Coalition Building
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Construction ICRA:
Best Practices in Healthcare Construction
A Collaborative Approach Meeting
the Needs of Health Care
Organizations…
• This Best Practices program is designed to
enhance the existing craft skills of UBC
members
• Its training is consistent with the CITF’s
standard protocol of industry-based,
expert-reviewed, certified-instructor
curriculum delivery
• The needs of the end-user remain a focal
point during training, so that UBC members
meet and exceed project expectations
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Construction ICRA:
Best Practices in Healthcare Construction
Working Together
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Healthcare facility managers who understand the procedures involved
in construction-related infection control help to reduce the risks
Architects who understand the specific risks involved help to
communicate the facility’s needs to the contractor
Contractors and workers who understand the issues involved when
working in a healthcare facility help to add value, safety and
professionalism to healthcare construction projects
Communication is key!
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Construction ICRA:
Best Practices in Healthcare Construction
Q&A
*Thank you for your time and we
enjoyed speaking to you about
our Construction ICRA Training*
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