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Health Care Construction
Patient Safety as Critical as Bricks, Mortar
by Paula Widholm
In the never-ending flow of expansions and renovations to aging health-care facilities, infection control is as vital as the bricks and mortar.
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The airborne spread of fungal spores and bacteria may cause
disease in susceptible individuals during hospital demolition,
renovation or construction projects. Microorganisms such as
mycobacterium tuberculosis and the rubeola and varicella viruses
can be dispersed widely by air currents and may become inhaled
by a susceptible host.
Patients most at risk include those with congenital or acquired
immunodeficiency syndromes, premature neonates and those receiving
immunosuppressive therapy (i.e. oncology or transplants).
Protecting vulnerable patients during construction requires
the use of impermeable barriers between patient care and construction
areas; directing pedestrian traffic away from the area to
prevent dust dispersal; and cleaning of the new premises before
patients are moved there.
Air and environmental monitoring for spores may also be required.
Assessing Risk
The construction industry is now writing infection control
precautions into contracts.
"It's a team effort between the hospital and the construction
team," says James Arends, senior health care services
manager in Chicago for Providence, R.I.-based Gilbane Building
Co., a contractor involved in 64 health-care projects nationwide
totaling $2.44 billion. "First we develop an infection
control-risk-assessment based on the extent of the construction
and how it's designed."
The multidisciplinary team approach coordinates the various
stages of construction activities. Environmental services,
employee health, engineering and infection control must be
represented in construction planning; and design meetings
should be convened with architects and design engineers.
Before initiating any construction, the team must consider:
Design and function of the new structure or area.
Assessment of environmental risks for airborne disease and
opportunities for prevention.
Measures to contain dust and moisture during construction.
"The design team will outline on the documents the existing
walls within the facility that can be investigated to determine
if they can be used as a barrier during construction activities,"
says Mark Nichols, principal of Chicago-based Loebl Schlossman
& Hackl, an architecture firm. "The design team can
also identify patterns of patient and construction traffic
that can be established on an interim basis during construction.
"This could impact exiting patterns within the facility,
so additional measures are put into place to identify and
insure all health, safety and welfare protocols are maintained."
Nichols adds that protocols often cover how construction personnel
and materials enter and leave the construction site, how the
construction site is separated physically from the patient
care areas and how the ventilation system is maintained in
the construction area so that it is isolated from the systems
that serve the patient care area.
Implementing Protocols
"Infection control procedures have been growing in sophistication
every year," Arends says. "We were first aware of
them in the early '90s. Everyone embraced it on the design
and construction side. To make sure we're doing it correctly
costs money."
Infection control measures add 22% to 30% to overall construction
costs at Children's Memorial Hospital, according to Roger
Johnson, administrator of facility services of the Chicago-based
facility. Unlike other hospitals, Children's Memorial contains
a high concentration of critically ill children that typically
aren't restricted to where they can go within the hospital.
"We take more precautions than most people," Johnson
says. "We have sealed partitions from floor to decks.
We require all areas to be at negative pressures, exhausting
more air than we let in. There are also a series of sticky
mats on the inside and outside of the construction area."
The mats remove debris and drywall dust off the bottom of
shoes.
"These special mats are used rather than just keeping
a rug wet, because a wet rug can promote fungus growth that
is sometimes worse than dust," he added. "It's just
another measure to make sure nothing gets tracked into the
hospital and becomes airborne," Arends said.
Keeping negative pressure through a construction ventilation
system that exhausts directly to the outside of the building
is standard procedure. Simple monitoring devices can be installed
within construction partitions to verify that this negative
pressure is always in place, Nichols says.
Plastic tents are used just to pop ceiling tile at Children's
Memorial. "It's all folded into the design phase,"
Johnson says. "We don't want any contractor not knowing
precautionary measures. The infection control people OK the
final design."
When construction materials must be removed from the site
through the occupied areas of the health-care facility, infection
control procedures must be established to cover these items
appropriately during transport so that dust cannot spread.
The workers themselves are often required to "gown-up"
with protective apparel when leaving a construction site in
order to cover clothing and shoes.
"It is best to always have a path the construction team
can take to move from the construction site immediately away
from the patient care areas whenever possible," Nichols
says.
Keeping Calm
Vibrations from construction also need to be minimized. For
instance, the earth-retention system would be altered to drilling
augers instead of pounding sheet piling. "You could also
create a slurry wall to isolate what you're doing," Arends
says.
Nichols adds: "Surgery and other procedures within the
hospital have low tolerance for disruption due to noise and
vibration. The construction team must work closely with the
hospital representative to coordinate construction activities
that will be scheduled at times other than when sensitive
procedures are taking place.
"This may require that these activities be scheduled
at off-hours, which can add cost and time to the construction
scope. This can also be a double-edged sword in that off-hour
construction may impact the quality of rest for patients staying
in the hospital who are trying to sleep."
Construction noise can also frustrate patients and staff.
On one large hospital project Arends recalled giving all hospital
patients and workers portable compact disk players because
of the noise from the jackhammers. "Even though it's
outside and far away, there's nothing to drown it out,"
he says.
Most health-care organizations will not hire firms without
health-care experience. "Every trade person from the
subcontractor has to go through training in the components
of infection control," Arends says. "If we see something
not right that's in the written contract, we can have that
person removed."
The special care extends to ensuring construction does not
disrupt the normal operation of emergency rooms. Coordination
is done with local ambulance providers.
"We notify them of anything that would impede the normal
route," Arends said. "We give out maps and provide
dates of the changes so there is no confusion. We also ask
them to weigh in on the changes."
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