construction issues in healthcare: challenges and strategies

Construction Issues Construction Issues in Healthcare: in Healthcare: Challenges and Challenges and Strategies Strategies

Andrew J. Streifel MPH, REHSAndrew J. Streifel MPH, REHSJoan M. Wideman MS, MS, MT(ASCP)SLS, CICJoan M. Wideman MS, MS, MT(ASCP)SLS, CIC

AIHceAIHce 2004 2004 -- Streifel & WidemanStreifel & Wideman

Session ObjectivesSession Objectives1.1. Provide at least one example of an infectious Provide at least one example of an infectious

microbe spread by each major route.microbe spread by each major route.2.2. List at least two instruments that may be List at least two instruments that may be

used to evaluate parameters during used to evaluate parameters during construction and renovation projects in the construction and renovation projects in the HC environment. HC environment.

3.3. Identify at least one method to reduce risk Identify at least one method to reduce risk of infectious spread by each route. of infectious spread by each route.


Our Evolving Healthcare (HC)Our Evolving Healthcare (HC)•• Over 6000 hospitals; > 1 M beds in USOver 6000 hospitals; > 1 M beds in US•• Shifts in services Shifts in services ––> 75% to outpatient> 75% to outpatient•• Aging population = demand LTCF & SNFAging population = demand LTCF & SNF•• ~ 2M HC associated infections/yr~ 2M HC associated infections/yr•• ~ 90,000 deaths/yr~ 90,000 deaths/yr•• ~ 5,000 related to ~ 5,000 related to

environmental microbesenvironmental microbes


Our Evolving HC SettingsOur Evolving HC Settings•• Technology & knowledge Technology & knowledge •• Persons at risk Persons at risk

–– ImmunocompromisedImmunocompromised–– Many causes; may not be obviousMany causes; may not be obvious

•• disease, medication, infection, disease, medication, infection, chemicals, radiation, personal factorschemicals, radiation, personal factors

•• changes with timechanges with time–– Those in hospitals are “sicker”Those in hospitals are “sicker”–– Treatment in ambulatory settingsTreatment in ambulatory settings–– Invasive devices and proceduresInvasive devices and procedures


Levels of ImmunityLevels of Immunity☺☺ Healthy personHealthy person•• Chronic obstructive pulmonary diseaseChronic obstructive pulmonary disease•• DiabetesDiabetes•• SteroidsSteroids•• Cancer Cancer -- solid tumorsolid tumor•• HIV infectionHIV infection--end stage of spectrumend stage of spectrum•• Organ transplantOrgan transplant

–– Kidney/heartKidney/heart–– Lung/liverLung/liver

•• Malignancy Malignancy -- leukemia/lymphoma leukemia/lymphoma Bone marrow transplant (BMT)Bone marrow transplant (BMT) allograftallograft


•• From CDC, ID Society of America, American From CDC, ID Society of America, American Society of Blood & Marrow TransplantationSociety of Blood & Marrow Transplantation

•• HSCT = HSCT = hematopoietichematopoietic stem cell transplant stem cell transplant •• Increasingly used Increasingly used TxTx neoplastic diseases,neoplastic diseases,

hematologichematologic disorders, immunodeficiency disorders, immunodeficiency syndromes, congenital enzyme deficiencies, & syndromes, congenital enzyme deficiencies, & autoimmune disorders (e.g., SLE or MS) autoimmune disorders (e.g., SLE or MS)

•• About 20,000 About 20,000 HSCTs HSCTs were done in 1998were done in 1998•• HSCT recipients are presumed HSCT recipients are presumed immunocompetentimmunocompetent

at 24 months after HSCT if they:at 24 months after HSCT if they:–– are not on immunosuppressive therapyare not on immunosuppressive therapy–– do not have graftdo not have graft--versusversus--host disease (GVHD)host disease (GVHD)

Guideline for Preventing Opportunistic Guideline for Preventing Opportunistic Infections AmongInfections Among HematopoieticHematopoietic Stem Stem

Cell Transplant RecipientsCell Transplant Recipients


Guideline for Preventing Opportunistic Infections AmongGuideline for Preventing Opportunistic Infections AmongHematopoieticHematopoietic Stem Cell Transplant Recipients Stem Cell Transplant Recipients –– MMWR 2000MMWR 2000


HC Facility ChallengesHC Facility Challenges•• HC is highly regulatedHC is highly regulated•• Resources extremely limitedResources extremely limited•• Buildings need repair & remediationBuildings need repair & remediation•• Environmental disturbances from Environmental disturbances from

daily operations daily operations major projectsmajor projects•• Aging equipment, deferred Aging equipment, deferred

maintenance, & natural disasters = maintenance, & natural disasters = “opportunities” for microbes“opportunities” for microbes


Infection Control BasicsInfection Control Basics•• Microbial RoutesMicrobial Routes

–– AirborneAirborne–– WaterborneWaterborne–– Surface TransferSurface Transfer

•• IC approach is similar IC approach is similar to IH tenetsto IH tenets–– AnticipateAnticipate–– RecognizeRecognize–– EvaluateEvaluate–– ControlControl


•• Pathogen Pathogen –– a microbe capable of causing a microbe capable of causing host damage; [classical & opportunistic host damage; [classical & opportunistic pathogens] damage = direct microbial pathogens] damage = direct microbial action or host immune responseaction or host immune response

•• Virulence Virulence –– relative capacity of microbe to relative capacity of microbe to cause damage in hostcause damage in host

•• Virulence factor Virulence factor –– component of a pathogen component of a pathogen that damages the hostthat damages the host

A Few Basic [Proposed] Terms A Few Basic [Proposed] Terms

CasadevallCasadevall A,A, PirofskiPirofski L. HostL. Host--Pathogen Interactions: The Attributes of Pathogen Interactions: The Attributes of Virulence. Journal of Infectious Diseases (2001)184:337Virulence. Journal of Infectious Diseases (2001)184:337--44.44.


Airborne Routes: PeopleAirborne Routes: People•• Reservoir = lungs, Reservoir = lungs,

nose, mouthnose, mouth•• Respiratory spreadRespiratory spread

–– droplet nuclei = remain droplet nuclei = remain suspendedsuspended

–– respiratory secretions respiratory secretions = close range= close range


Airborne ParticlesAirborne Particles•• DisruptionsDisruptions•• Housekeeping, Housekeeping,

maintenance, maintenance, renovation and renovation and construction activitiesconstruction activities

•• Consider internal & Consider internal & external sourcesexternal sources

•• Amplification Amplification opportunitiesopportunities


Airborne Infectious AgentsAirborne Infectious Agents

•• Tuberculosis (TB)Tuberculosis (TB)•• ChickenpoxChickenpox•• Zoster “shingles”Zoster “shingles”

–– in certain patientsin certain patients•• MeaslesMeasles•• Certain bioterrorism agentsCertain bioterrorism agents


Aspergillus: Aspergillus: A.fumigatus,A.fumigatus, et alet al


Aspergillus fumigatusAspergillus fumigatus


•• In 1996 dollars, average cost $62,426In 1996 dollars, average cost $62,426–– Range $52,670 Range $52,670 -- $72,181$72,181

•• Often as a secondary diagnosis (73%)Often as a secondary diagnosis (73%)–– Respiratory, neoplastic and HIV most common Respiratory, neoplastic and HIV most common

primary diagnosisprimary diagnosis•• Increased length of stayIncreased length of stay

–– Average hospitalization 17.3 daysAverage hospitalization 17.3 days–– Range 16.1 Range 16.1 –– 18.6 days18.6 days

•• Costs don’t include mortalityCosts don’t include mortality

Costs of AspergillosisCosts of Aspergillosis

DasbachDasbach et al, Clinical Infectious Diseases 2000;31:1524et al, Clinical Infectious Diseases 2000;31:1524--88


Fungal Infections KillFungal Infections Kill


Waterborne RoutesWaterborne Routes

•• Direct contact (hydrotherapy)Direct contact (hydrotherapy)•• Ingestion of water (drinking Ingestion of water (drinking

water, ice)water, ice)•• Indirect contact (improperly Indirect contact (improperly

reprocessed medical device)reprocessed medical device)•• Inhalation of aerosols Inhalation of aerosols

(showers)(showers)•• Aspiration Aspiration -- contaminated contaminated

waterwater


Waterborne MicrobesWaterborne Microbes•• Legionella spp.Legionella spp.•• PseudomonasPseudomonas spp. spp. •• AeromonasAeromonas spp.spp.•• Other gram negative bacteriaOther gram negative bacteria•• Mycobacteria (TB & NTM)Mycobacteria (TB & NTM)•• Yeasts and other fungiYeasts and other fungi•• ParasitesParasites

–– The BUG that made Milwaukee The BUG that made Milwaukee famousfamous

–– AmoebaAmoeba


Waterborne InfectionsWaterborne Infections•• Many cases citedMany cases cited•• Causes varyCauses vary•• Single case vs. outbreakSingle case vs. outbreak•• Distinguish healthcare Distinguish healthcare

associated (nosocomial) from associated (nosocomial) from community acquired infectioncommunity acquired infection–– Determine source: supply vs. Determine source: supply vs.

healthcare facility vs. reservoirhealthcare facility vs. reservoir•• Many unrecognized casesMany unrecognized cases•• Biofilms Biofilms protect & insulateprotect & insulate


Surface RoutesSurface Routes•• NonNon--intact skinintact skin•• Injection & inoculationInjection & inoculation•• Fomite Fomite transfertransfer•• SelfSelf--inoculation (e.g., inoculation (e.g.,

mucous membranes)mucous membranes)


Surface MicrobesSurface Microbes•• Bloodborne PathogensBloodborne Pathogens

–– Hepatitis B & C, HIVHepatitis B & C, HIV•• Bacteria Bacteria –– various typesvarious types

–– Gram positive & gram negative; Gram positive & gram negative; sporesspores

–– May or may not be “pathogenic”May or may not be “pathogenic”–– Cleaning & disinfection, as Cleaning & disinfection, as

appropriateappropriate•• Fungi, algae Fungi, algae –– difficult to removedifficult to remove


AnticipationAnticipation•• Healthcare facilities are uniqueHealthcare facilities are unique

–– Protect persons (patients, workers, Protect persons (patients, workers, visitors, others) plus our facilityvisitors, others) plus our facility

–– Microbes are there; will they cause Microbes are there; will they cause morbidity (illness) or mortality (death)?morbidity (illness) or mortality (death)?

–– Persons at risk don’t wear a sign nor are Persons at risk don’t wear a sign nor are they necessarily in a bed they necessarily in a bed

–– Daily operations through major projects Daily operations through major projects disrupt environment disrupt environment

•• How do we recognize?How do we recognize?•• Best method(s) to evaluate?Best method(s) to evaluate?•• What and how can we control?What and how can we control?


•• Seven major areas covered:Seven major areas covered:–– Air Air –– WaterWater–– Environmental Services Environmental Services –– Environmental Sampling Environmental Sampling –– Laundry and BeddingLaundry and Bedding–– Animals in Healthcare FacilitiesAnimals in Healthcare Facilities–– Regulated Medical WasteRegulated Medical Waste

•• MMWR 6MMWR 6--03 was 03 was partialpartial documentdocument•• 249 pg. with >1400 citations249 pg. with >1400 citations•• Appendices A Appendices A –– F F

Guidelines for Environmental Guidelines for Environmental Infection Control in HCFInfection Control in HCF


Using an ICRA MatrixUsing an ICRA Matrix1.1. Type of Project ActivityType of Project Activity2.2. Patient Risk GroupsPatient Risk Groups

•• ImmunocompromisedImmunocompromised•• Invasive procedures/devicesInvasive procedures/devices

3.3. Class of IC Precautions Class of IC Precautions based upon parametersbased upon parameters

“IC Permit” assists documentation“IC Permit” assists documentation

AIHceAIHce 2004 2004 -- Streifel & WidemanStreifel & WidemanICRA Matrix at www.ICRA Matrix at www.asheashe.org.org


Sample ICRA MatrixSample ICRA MatrixPATIENT Risk Group TYPE ATYPE A TYPE BTYPE B TYPE CTYPE C TYPE DTYPE D

LOWLOWRisk Group II II II III / IV

MEDIUMMEDIUMRisk Group I II III IV

HIGHHIGHRisk Group I II III / IV IV

HIGHESTHIGHESTRisk Group II III / IV III / IV IV


Control MethodsControl Methods•• Infection Control Risk Assessment Infection Control Risk Assessment

(ICRA) team approach(ICRA) team approach•• Design decisionsDesign decisions•• Expectations to contractorsExpectations to contractors•• Education & trainingEducation & training•• Equipment for the jobEquipment for the job•• Instruments for measuringInstruments for measuring•• Surveillance = outcome & processSurveillance = outcome & process•• CommunicationCommunication•• DocumentationDocumentation


People: Control MeasuresPeople: Control MeasuresRecognize potential disease (e.g., TB)Recognize potential disease (e.g., TB)Airborne Infection Isolation (AII) Airborne Infection Isolation (AII) •• NPV required (HVAC)NPV required (HVAC)

–– Daily testing (OSHADaily testing (OSHA--TB)TB)–– Label ductworkLabel ductwork–– Local exhaustLocal exhaust--proceduresprocedures

•• Healthcare workersHealthcare workers–– Skin testing / evaluation Skin testing / evaluation –– Respiratory protectionRespiratory protection–– Training & educationTraining & education

•• Mask source = patientMask source = patient

CDCCDC


Protect the Protect the Patient and Patient and EnvironmentEnvironment

Protect the Worker Protect the Worker and Environmentand Environment


AII Pressure AII Pressure >> 0.01 “wg (2.5 Pa)0.01 “wg (2.5 Pa)Per CDC/HICPAC Guidelines Environmental ICPer CDC/HICPAC Guidelines Environmental IC

Negative pressure = air into roomNegative pressure = air into roomClean to dirty air flowClean to dirty air flow


Example Two “ganged” AnteroomExample Two “ganged” Anteroom

Two rooms ganged with Two rooms ganged with shared anteroomshared anteroom

•• must emphasize must emphasize separate storageseparate storage

•• control/monitoringcontrol/monitoring

If allowedIf allowed•• PPE & contaminated PPE & contaminated

items must be kept items must be kept separateseparate

PAT IE N T R O O M

PAT IE N T R O O M

C O R R ID O R

A n te ro o m

B A T H R O O M

B A T H R O O M


monitormonitor

corridorcorridor

Protective Isolation (PI)Protective Isolation (PI)Compromised Patient with InfectionCompromised Patient with Infection

•• pressure differential @ >2.5 Pascal's or 0.01"w.g. ideal at pressure differential @ >2.5 Pascal's or 0.01"w.g. ideal at 0.030.03””wgwg or 8 Pascalor 8 Pascal’’ss--range from 2.5 to 8.0 Parange from 2.5 to 8.0 Pa

•• positive pressure greater supply than exhaust air volumepositive pressure greater supply than exhaust air volume•• greater than 125greater than 125 cfmcfm airflow differential supplyairflow differential supply vsvs exhaustexhaust•• sealed room; about 0.5 sq feet leakagesealed room; about 0.5 sq feet leakage•• clean to dirty airflowclean to dirty airflow•• monitoringmonitoring•• >12 air exchanges per hour>12 air exchanges per hour•• recirculaterecirculate air back through filtersair back through filters

Intended UsagesIntended Usagesimmune compromised patient roomsimmune compromised patient rooms

operating roomsoperating rooms (OR)(OR)


monitorante room

corridor

bathroom

monitorante room

corridor

bathroom

normal

immunecompromised

monitorante room

corridor

bathroomimmune

compromised

Airborne Infection Isolation Room with Anteroom

•• pressure differential @ 2.5 Pascal's or 0.01“ w.g.,pressure differential @ 2.5 Pascal's or 0.01“ w.g.,•• sealed room with about 0.5 sq. ft leakagesealed room with about 0.5 sq. ft leakage•• greater than 125greater than 125 cfmcfm airflow differential Supplyairflow differential Supply vsvs ExhaustExhaust•• clean to dirty airflowclean to dirty airflow•• monitoringmonitoring•• >12 air exchanges per hour new or 6 ac/hr renovation>12 air exchanges per hour new or 6 ac/hr renovation•• anteroom airflow patterns anteroom airflow patterns


Air changes/hour (ACH) and time required for Air changes/hour (ACH) and time required for airborneairborne--contaminant removalcontaminant removal

Time (mins.) required for removal:ACH+ § ¶ 99% efficiency 99.9% efficiency

2 138 2074 69 1046 46 698 35 5210 28 4112 23 3515 18 2820 14 2150 6 8

This table is revised from Table S3This table is revised from Table S3--1, 1994 CDC TB Guidelines & has been adapted from 1, 1994 CDC TB Guidelines & has been adapted from the formula for the rate of purging airborne contaminants presenthe formula for the rate of purging airborne contaminants presented in reference 1435.ted in reference 1435.+ Shaded entries denote frequently cited ACH for patient+ Shaded entries denote frequently cited ACH for patient--care areas.care areas.§§ Values were derived from the formula:Values were derived from the formula:

tt22 –– tt11 = = –– [[ln ln (C(C22 / C/ C11) / (Q / V)] ) / (Q / V)] XX 60, with t60, with t11 = 0 and where= 0 and where

tt11 = initial= initial timepoint timepoint in minutesin minutes tt22 = final= final timepoint timepoint in minutesin minutesCC11 = initial concentration of contaminant C= initial concentration of contaminant C22 = final conc. of contaminant= final conc. of contaminantCC22 / C/ C11 = 1 = 1 –– (removal efficiency / 100)(removal efficiency / 100) Q = air flow rate in cubic feet/hourQ = air flow rate in cubic feet/hourV = room volume in cubic feetV = room volume in cubic feet Q / V = ACHQ / V = ACH


Room Leakage AreasRoom Leakage Areas•• Airflow leakage occurs around:Airflow leakage occurs around:

–– plumbing connectionsplumbing connections–– medical gases medical gases –– electrical/video connectionelectrical/video connection–– lightinglighting–– ceilingsceilings–– windows/doors windows/doors –– door cracksdoor cracks–– in wall mounted fixturesin wall mounted fixtures


Electronic MonitorElectronic Monitor

Flutter StripFlutter Strip

Simple Flutter StripSimple Flutter Strip

Liquid ManometersLiquid Manometers

Calibrated PingCalibrated Ping--PongPong


Filters Filters –– Variety of TypesVariety of Types

PleatedPleated MultiMulti--pocket Bagpocket Bag

HEPA in HEPA in ductworkductwork Filter frames Filter frames

for filter mediafor filter media

Typical Typical “Furnace “Furnace Filters”Filters”


Measured removal efficiency should be Measured removal efficiency should be within 10% of the expected values. within 10% of the expected values.

ASHRAE Filter Rating (Estimated Minimum Efficiency Reporting Value, MERV)

ASHRAE Filter Rating (Estimated Dust Spot, % efficiency)

Expected Reduction of Ultrafine Particles (%)

Measured Concentration of Ultrafine Particles pt/cm3)

N/-A No Filter (Ambient)

0 10,000

N/A HEPA 100 <1 15 95 90-93 700-1,000 14 90-95 85 1500 11 60 35-40 6,000-6,500 9 40 20-30 7,000-8,000 8 <30 10-20 8,000-9,000

Filter Efficiency and Particle CountsFilter Efficiency and Particle Counts


Testing For Filter InefficiencyTesting For Filter Inefficiency“in“in situsitu” filter ” filter testing with testing with condensation condensation particle counterparticle counter


•• Gasket seals or failure; missing gasketsGasket seals or failure; missing gaskets•• Duct leakageDuct leakage•• Clogged, damaged, or incorrect filtersClogged, damaged, or incorrect filters•• Dust on fan bladesDust on fan blades•• Fan belt slippageFan belt slippage•• Plugged/dirty temperature control coilsPlugged/dirty temperature control coils•• UncalibratedUncalibrated control equipmentcontrol equipment

–– Temperature sensors, thermostat, humidity Temperature sensors, thermostat, humidity control, receiver controlscontrol, receiver controls

•• High air velocityHigh air velocity

Causes of “Filtration Failure”Causes of “Filtration Failure”


Filter Action SummaryFilter Action Summary•• Filters do not act like sievesFilters do not act like sieves•• Single fiber mechanismsSingle fiber mechanisms

–– Impaction increases with increasing d or UImpaction increases with increasing d or U–– Diffusion increases with decreasing d or UDiffusion increases with decreasing d or U–– Interception increases with increasing dInterception increases with increasing d

•• Consider particle diameter for minimum Consider particle diameter for minimum efficiencyefficiency

•• Efficiency and resistance increase with Efficiency and resistance increase with loading (to a point)loading (to a point)

d = diameter of particle; U = face velocity = Q / Ad = diameter of particle; U = face velocity = Q / A


••Particle counters tell the Particle counters tell the rank orderrank order

••Pressure gauges give air Pressure gauges give air velocityvelocity

••Balancing hoods verify air Balancing hoods verify air exchangesexchanges

These parameters should These parameters should be kept stable and should be kept stable and should be checked when changes be checked when changes or adjustments are made or adjustments are made in HVAC systemin HVAC system


Control AirborneControl Airborne--ProjectsProjects•• Pressure managementPressure management

–– Barrier airflow controlBarrier airflow control–– > 0.01”> 0.01”wgwg (>2.5 (>2.5 PascalsPascals))

•• TransportTransport–– Personnel and materialsPersonnel and materials–– Track dirtTrack dirt

•• Water damage protocolsWater damage protocols–– Water resistant materialsWater resistant materials–– Early detectionEarly detection

•• TrainingTraining–– Supervisors and workersSupervisors and workers–– Area tenantsArea tenants


Control: Dust ContainmentControl: Dust Containment


Portable ContainmentPortable Containment


Control Control –– Negative PressureNegative Pressure


Sampler criteriaSampler criteria• high volume• high volume• lab friendly• lab friendly• culture methods• culture methods

SieveSieve impactorsimpactors

SlitSlitimpactorimpactor

Optical Optical particle particle countercounter


Unresolved Issues and Unresolved Issues and Microbiologic Air SamplingMicrobiologic Air Sampling

•• Unknown incubation period for IPAUnknown incubation period for IPA•• Infectious dose for Infectious dose for AspergillusAspergillus spp. is spp. is

unknownunknown•• Lack of standard sampling protocolsLack of standard sampling protocols•• Variability & sensitivity of sampling devicesVariability & sensitivity of sampling devices•• Lack of details re: sampling makes comparison Lack of details re: sampling makes comparison

of results with other outbreaks difficultof results with other outbreaks difficult•• Lack of correlation between fungal strains in Lack of correlation between fungal strains in

clinical specimens & those found in the clinical specimens & those found in the environmentenvironment


Reasons to Sample AirReasons to Sample Air•• Preoccupancy verification of ventilation & Preoccupancy verification of ventilation &

cleanlinesscleanliness–– establish baseline data (based on particle removal)establish baseline data (based on particle removal)–– BMTU,BMTU, ORsORs, NICU, other critical areas, NICU, other critical areas

•• Post infection evaluation (outbreak?)Post infection evaluation (outbreak?)–– verification of baseline dataverification of baseline data–– rule out ventilation as sourcerule out ventilation as source–– discover source of infectious fungi (reservoir?)discover source of infectious fungi (reservoir?)

•• Routine surveillanceRoutine surveillance–– not recommended (CDC)not recommended (CDC)–– provides assurance of status quoprovides assurance of status quo–– may be useful for finding deviations in baseline datamay be useful for finding deviations in baseline data


DefinitionsDefinitions•• cfucfu=colony forming units=colony forming units•• m^3 = cubic meter of airm^3 = cubic meter of air•• 28.3 liters = 1ft^328.3 liters = 1ft^3•• 35.3ft^3 = 1.0m^335.3ft^3 = 1.0m^3•• homogeneous population=majority of isolates samehomogeneous population=majority of isolates same•• heterogeneous population=mixture of isolatesheterogeneous population=mixture of isolates•• viable=living organismviable=living organism•• nonviable=not capable of reproducingnonviable=not capable of reproducing•• aggressive=sampling while disturbing the environmentaggressive=sampling while disturbing the environment•• quiescent(passive) = sampling not disturbing quiescent(passive) = sampling not disturbing

environmentenvironment•• thermotolerantthermotolerant=likes >35C temperature for growth=likes >35C temperature for growth•• room temperature = growth incubation at 25Croom temperature = growth incubation at 25C


Spores collected for identification Spores collected for identification by light microscopy = difficult to by light microscopy = difficult to distinguish between Aspergillus & distinguish between Aspergillus & Penicillium speciesPenicillium species

Culture & microscopicCulture & microscopicevaluations should be usedevaluations should be usedclinical area(s) clearanceclinical area(s) clearance

•• Long term sampling (2 liters/min)Long term sampling (2 liters/min)•• Not size selectiveNot size selective•• Drying out; nonviable spore countsDrying out; nonviable spore counts•• Many spores not Many spores not ID’dID’d to genusto genus•• Rank order determinationRank order determination

Cassette Air Cassette Air SamplesSamples


Baseline Data DevelopmentBaseline Data Developmentin Healthcare Air Samplingin Healthcare Air Sampling

•• Provides verification of filtration efficacyProvides verification of filtration efficacy–– Should show relative drop of viable/nonShould show relative drop of viable/non--culture particlesculture particles–– Should show Should show >> 90% drop of particles for 90% efficient filters90% drop of particles for 90% efficient filters–– NonNon--cultured particle analysis should use > 0.5 cultured particle analysis should use > 0.5 µm µm particle sizeparticle size

•• Provides microProvides micro--flora verification in affected spaceflora verification in affected space–– Air is not sterile; should reflect isolates similar to outsideAir is not sterile; should reflect isolates similar to outside–– Baseline should compare data from indoor space & outdoorsBaseline should compare data from indoor space & outdoors

•• Baseline data is best established preBaseline data is best established pre--occupancyoccupancy–– Ventilation systems should be working according to specsVentilation systems should be working according to specs–– Testing should be finished & specified ventilation parameters Testing should be finished & specified ventilation parameters

assuredassured–– Ideally sampling should be conducted before occupancy to Ideally sampling should be conducted before occupancy to

avoid variablesavoid variables


Interpretation of DataInterpretation of Data•• Rank order analysisRank order analysis

–– Lowest counts in areas with best filtrationLowest counts in areas with best filtration–– Comparison necessary with outdoor controlComparison necessary with outdoor control

•• Qualitative analysisQualitative analysis–– Pathogen recovery (Aspergillus)Pathogen recovery (Aspergillus)–– Homogeneous population (v. heterogeneous)Homogeneous population (v. heterogeneous)

•• Indoor / Outdoor ratioIndoor / Outdoor ratio–– I/O <1 normal (seasonal considerations)I/O <1 normal (seasonal considerations)–– I/O >1 potential problemI/O >1 potential problem

•• Temperature selectivityTemperature selectivity–– Pathogens grow best at >35º CPathogens grow best at >35º C–– Filtration efficacy determined at 25º CFiltration efficacy determined at 25º C


Seasonal variation isSeasonal variation isdependant on the climatedependant on the climateand local floraand local flora

Local sources can createLocal sources can createhigh dosehigh dose--short termshort termexposuresexposures

Exposure VariationExposure Variation


What did water do What did water do under this sink?under this sink?

Mold growth causedMold growth causedthe I/O ration to be >1the I/O ration to be >1

Indoor variation is Indoor variation is dependant on dependant on local sources & filtrationlocal sources & filtration


50%na5300Adjacent bldg.

90%na1000Radiation therapy

99.97%na0-1Diffusers

99.97%(+) 11 & 12>500-2/32 rooms99.97%(+) 8.6-1710-80-9/32 rooms

99.97%(+) 6.8-30<10-21/32 rooms

99.97%(+) 4-10450BMT area corridor

90%na 1500Lobby---------na8500Outside

Example of Air Particle Analysis Example of Air Particle Analysis Using Condensate Particle CounterUsing Condensate Particle Counter

Particles/ccParticles/cc Pressure (Pressure (PascalsPascals) ) Filter efficiencyFilter efficiency

Demonstrates rank order and pressureDemonstrates rank order and pressure


Summary: MeasurementsSummary: Measurements•• Airborne particlesAirborne particles

–– filter efficacy: compare with other areas & outsidefilter efficacy: compare with other areas & outside–– activity factor around constructionactivity factor around construction–– beware of internal nuisance sources of particlesbeware of internal nuisance sources of particles

•• PressuresPressures–– provides airflow intensity for clean to dirty airflowprovides airflow intensity for clean to dirty airflow–– pressure is a measure of air velocitypressure is a measure of air velocity

•• 0.001”0.001”wgwg = 100 linear ft/min= 100 linear ft/min•• 0.01”0.01” wgwg = 400 = 400 lfpmlfpm•• 0.1”0.1”wgwg = 1300= 1300 lfpmlfpm

•• Air exchangesAir exchanges–– purge rate with clean airpurge rate with clean air–– air changes correlate with % particle reductionair changes correlate with % particle reduction–– 12 ACH = 99.9% reduction in 35 minutes12 ACH = 99.9% reduction in 35 minutes–– how long to wait to remove contagious particles?how long to wait to remove contagious particles?


MOLDMOLD

Water Damage ManagementWater Damage Management•• ReactiveReactive

–– respond to water incidentrespond to water incident–– determine extent of water damagedetermine extent of water damage–– cut out or drycut out or dry

•• ProactiveProactive–– water resistant materialwater resistant material–– preservative applicationpreservative application–– proper installationproper installation


Damage Due to Water IntrusionDamage Due to Water Intrusion

•• Management of wet, porous building Management of wet, porous building materials, furniture, carpeting:materials, furniture, carpeting:–– Remove porous building materials and replace if Remove porous building materials and replace if

they cannot dry out within 72 hours (I.e., > 20% they cannot dry out within 72 hours (I.e., > 20% moisture as measured by moisture meter)moisture as measured by moisture meter)

–– Wet down carpeting with a lowWet down carpeting with a low--level level disinfectant prior to removal; allow supporting disinfectant prior to removal; allow supporting structure underneath to dry out; replace tiles structure underneath to dry out; replace tiles or carpetingor carpeting

–– Wood furniture removed for drying, sanding as Wood furniture removed for drying, sanding as needed and reneeded and re--varnishing; replace cloth varnishing; replace cloth furnishingsfurnishings


ConstructionConstruction--Related Roof LeakRelated Roof LeakConstruction schedules: Construction schedules: difficult to coordinatedifficult to coordinate

Roofer behind schedule Roofer behind schedule while sheetrock aheadwhile sheetrock ahead

Water damage requires Water damage requires immediate responseimmediate response


What is the differenceWhat is the differencein these shaft walls?in these shaft walls?--Luck?Luck?--Better materials?Better materials?--Construction mgmt?Construction mgmt?--All of the above?All of the above?


Moisture MeterMoisture Meter-- decision makerdecision maker-- find the wetnessfind the wetness-- drying timedrying time-- <72 hrs<72 hrs


IR Thermometer Can Detect WetnessIR Thermometer Can Detect Wetness

Warm surfaceWarm surface Cool surfaceCool surface


Temporary Drying UnitTemporary Drying Unit


Leaking Roof Water Damage AreaLeaking Roof Water Damage Area

Water Water AccumulatedAccumulated

in thein theFloor RailFloor Rail

Water Migrated Water Migrated to Variousto VariousLocationsLocations


Worker with Respiratory ProtectionWorker with Respiratory Protectionand Protective Clothingand Protective Clothing

HEPA VacuumingHEPA Vacuuming

Worker Protection forWorker Protection forCleaning Wall CavityCleaning Wall Cavity


Water Damaged Patient Care UnitWater Damaged Patient Care UnitHorizontal Surface Contact SamplingHorizontal Surface Contact Sampling

Date No. plates Total fungi A. Fumigatus

09/15/9409/27/9410/09/94

8 8 8

>265 65 9

155 5 0

11/04/9411/18/94

4 4

27 12

1.5 1

12/07/9412/08/94

4 6

<1 1.3

0 0

12/14/9412/15/94

7 7

1 1.2

0 0

12/20/9412/22/94

6 7

1 1.3

0 0


Sheetrock & Sheetrock & insulation wick insulation wick

up waterup water

Find the water with a detectorFind the water with a detector

Barrier up within 36 hrsBarrier up within 36 hrs


If you can’t dry it If you can’t dry it --> cut it out!!> cut it out!!

Or keep the rock Or keep the rock off the slab!off the slab!


Condensation and Other Condensation and Other Moisture SourcesMoisture Sources

•• Source of moistureSource of moisture–– Internal or externalInternal or external

•• Internal sourceInternal source–– Leaks in plumbingLeaks in plumbing–– Stagnant waterStagnant water–– Water featuresWater features–– Excess humidification chill water Excess humidification chill water

capacitycapacity•• External sourceExternal source

–– Windows, flashingWindows, flashing–– LandscapingLandscaping–– Depressurized buildingDepressurized building


Steel Girders Steel Girders AttractAttract

CondensationCondensation

Sheet Rock Sheet Rock Gives the Gives the

Asbestos TeamAsbestos Teama Workouta Workout

AIHceAIHce 2004 2004 -- Streifel & WidemanStreifel & Widemanwww.www.dehsdehs..umnumn.edu/.edu/iaqiaq

Water Intrusion Algorithms Water Intrusion Algorithms


ControlControl--WaterborneWaterborne•• Design Design –– potable water; cooling towerspotable water; cooling towers•• MaintenanceMaintenance•• Temperature >140° F?Temperature >140° F?•• Treatment of waterTreatment of water

–– Municipal sourceMunicipal source–– InIn--hospital treatmenthospital treatment

•• Source recognitionSource recognition–– Water reservoirsWater reservoirs–– DeadDead--legs & dormantlegs & dormant

•• Flushing preFlushing pre--occupancyoccupancy


44

TransmissionTransmissionHumidity Humidity

Droplet SizeDroplet SizeDistanceDistance

66

Multiply inMultiply inHumanHuman

VirulenceVirulence

22

AmplificationAmplificationMicrobial AssociationsMicrobial Associations

NutrientsNutrientsBiocidesBiocides

System CleanlinessSystem Cleanliness55

Susceptible HostSusceptible HostAge, Disease, Age, Disease,

ImmunodeficiencyImmunodeficiency

33

DisseminationDissemination(Aerosolization)(Aerosolization)

11

Survival in Survival in ReservoirReservoir

Temp, pH, Nutrients, Temp, pH, Nutrients, Microbial AssociationsMicrobial Associations

77

DiagnosisDiagnosisSymptoms, Lab Tests, Symptoms, Lab Tests,

SurveillanceSurveillance

Waterborne [Waterborne [LegionellaLegionella]]Transmission StepsTransmission Steps

Risk MinimizationRisk Minimization(Prevention)(Prevention)

Adapted from Barbaree Adapted from Barbaree ASHRAE 12ASHRAE 12--2000 2000


Potable Water TreatmentPotable Water Treatment

•• Active disinfectantActive disinfectant–– Chlorine Dioxide Chlorine Dioxide –– CopperCopper--SilverSilver–– ChloramineChloramine–– ChlorineChlorine

•• Point of usePoint of use–– Ultra Violet Ultra Violet –– OzoneOzone–– High TemperatureHigh Temperature


Cooling Towers and Cooling Towers and Evaporative CondensersEvaporative Condensers

•• Locate cooling towers so that the Locate cooling towers so that the drift is directed away from the drift is directed away from the airair--intake systemintake system

•• Design the towers to minimize the Design the towers to minimize the volume of aerosol driftvolume of aerosol drift

•• Implement IC procedures for Implement IC procedures for operational cooling towersoperational cooling towers–– Drift eliminators, biocide, Drift eliminators, biocide,

maintenance, decontaminationmaintenance, decontamination


Control Control -- SurfacesSurfaces•• ResponsibilitiesResponsibilities

–– Owner removes sharps, RMW, Owner removes sharps, RMW, equipment, reservoirsequipment, reservoirs

–– Protection for nonProtection for non--movable?movable?•• Design choicesDesign choices•• Cleaning vs. disinfection Cleaning vs. disinfection

–– EPA approved?EPA approved?–– Spills vs. routineSpills vs. routine–– Compatible with surfaceCompatible with surface

•• Chemical/physical hazardsChemical/physical hazards–– safety & risk hatssafety & risk hats


Swab samplesSwab samples• not quantitative• not quantitative• species ID for clearance• species ID for clearance

Surface samples can be Surface samples can be used to determine if used to determine if

surfaces are clean or if surfaces are clean or if organisms on the organisms on the

surfaces can be found in surfaces can be found in the airthe air


Surface contact media plates•culture of surface•test for cleaning•potential surface/air connection

•demonstrates surface contamination•APHA <25 cfu/plate satisfactory•use rank order, qualitative andquantitative analysis


Considerations Surface SamplingConsiderations Surface Sampling•• Background Background -- literature & present activities literature & present activities

–– e.g., preliminary results from epidemiological e.g., preliminary results from epidemiological investigationinvestigation

•• Locations to sample? Locations to sample? •• Collection method & equipment? Collection method & equipment? •• Number of replicate samples needed?Number of replicate samples needed?•• What controls or comparisons are required?What controls or comparisons are required?•• Parameters for assay method & whether Parameters for assay method & whether

sampling = qualitative, quantitative, or both?sampling = qualitative, quantitative, or both?•• Estimate of maximum allowable microbial Estimate of maximum allowable microbial

numbers or types on surface[s] sampled?numbers or types on surface[s] sampled?•• Some anticipation of a corrective action plan?Some anticipation of a corrective action plan?


Methods of Surface SamplingMethods of Surface Sampling

from CDC/HICPAC Guidelines Environmental ICfrom CDC/HICPAC Guidelines Environmental IC


Specify Duct CleanlinessSpecify Duct Cleanliness•• Sheet Metal and Air Conditioning Sheet Metal and Air Conditioning

Contractors’ National Association Contractors’ National Association (SMACNA) (SMACNA) –– Duct Cleanliness for Duct Cleanliness for New Construction Guidelines New Construction Guidelines (2000)(2000)–– A. Basic LevelA. Basic Level–– B. Intermediate LevelB. Intermediate Level–– C. Advanced LevelC. Advanced Level

•• Specify in contractSpecify in contract

www.www.smacnasmacna.org.org Photo courtesy of Rob Case, RCCSPhoto courtesy of Rob Case, RCCS


Protection of HVAC ductworkProtection of HVAC ductworkin new installationin new installation

Photo courtesy of Rob Case, RCCS


Environmental SurveillanceEnvironmental Surveillance•• Microbes Microbes

–– Air, water, surfacesAir, water, surfaces•• Ventilation parametersVentilation parameters

–– Air exchangesAir exchanges–– PressurePressure–– FiltrationFiltration

•• Construction & maintenance practiceConstruction & maintenance practice–– Intrusion recognitionIntrusion recognition–– Water response planWater response plan–– Mold recognition & cleanMold recognition & clean--upup–– Construction managementConstruction management–– Emergency responseEmergency response


Caution:Caution:Noise and Noise and vibrationvibration

Can cause distress for some Can cause distress for some patients/settings: premature neonates, patients/settings: premature neonates,

heart attack, stroke, psychiatric, & heart attack, stroke, psychiatric, & pediatricspediatrics


•• Association for Professionals in Association for Professionals in Infection Control and Infection Control and Epidemiology, Inc.Epidemiology, Inc.

•• MultiMulti--disciplinary voluntary disciplinary voluntary international organization with international organization with over 10,000 membersover 10,000 members

•• Purpose is to influence, support Purpose is to influence, support and improve the quality of HC and improve the quality of HC through the practice and through the practice and management of IC & the management of IC & the application of epidemiology in application of epidemiology in all health settingsall health settings


In SummaryIn Summary•• Understanding of concerns and Understanding of concerns and

controls assists the IH controls assists the IH professional in working within our professional in working within our evolving healthcare industryevolving healthcare industry

•• Infection Control practice aligned Infection Control practice aligned with Industrial Hygienewith Industrial Hygiene

•• Get to know the Infection Control Get to know the Infection Control Professional (ICP) in addition to Professional (ICP) in addition to other healthcare professionalsother healthcare professionals


Were Objectives Met?Were Objectives Met?

1.1. Provide at least one example of an infectious Provide at least one example of an infectious microbe spread by each major route.microbe spread by each major route.

2.2. List at least two instruments that may be List at least two instruments that may be used to evaluate parameters during used to evaluate parameters during construction and renovation projects in the construction and renovation projects in the HC environment. HC environment.

3.3. Identify at least one method to reduce risk Identify at least one method to reduce risk of infectious spread by each route. of infectious spread by each route.


Questions?Questions?

Andy = strei001@Andy = [email protected]

Joan = [email protected] = [email protected]

construction issues in healthcare: challenges and strategies

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