Page 1 of 6 I. PURPOSE To incorporate measures into facility construction or renovation design which will optimize infection prevention. In addition, this policy establishes means to minimize environmental sources of microbes during construction, renovation or facility maintenance activities. II. POLICY It is the policy of the University of California, Irvine Healthcare to use strategic facility design and safe construction, renovation and maintenance practices in order to promote optimal infection prevention for patient safety practices. For Construction or Renovation Construction or renovation projects in clinical and clinical support areas must have (EIP) input into both design planning and construction in order to optimize infection prevention. It is the responsibility of the Project Manager to notify EIP of construction or renovation projects in all clinical and clinical support areas. The Project Manager and design team will meet with EIP during design development to incorporate design considerations that promote infection prevention into the project. In addition, construction means and methods for infection prevention purposes that could have substantial budget impact will be discussed to allow inclusion in bid documents for contractors (See Appendix A: Design Development Considerations). Prior to work starting, a Pre-Construction Risk Assessment (PCRA) will be initiated by the Project Manager and performed for all construction and renovation projects (see Safety Policy: Pre-Construction Risk Assessment). This assessment includes measures for infection prevention during construction as well as other safety measures. Based on the degree of patient risk and the type of work to be performed, specific infection prevention measures will be required for each project. Whenever feasible, work will be performed in unoccupied spaces. In the High and Highest Risk Group areas, no work will be performed in immediate proximity of patients, food preparation or laboratory work without appropriate infection prevention safety measures..
General Page 2 of 6 For infection prevention purposes, a PCRA is not required for projects determined to be Class I or II. For Class III or IV projects, a written PCRA must be completed. Precautions will be communicated to both project workers and staff members of the immediate work area. All staff, contractors, subcontractors, material suppliers, and vendors are required to follow the precautions defined in the PCRA. The PCRA must be completed and precautions put into place by the Project Manager prior to the start of work. A PCRA will also be performed for exterior work if it is determined by the Project Manager that the work will raise plumes of dust or soil, intrude into existing water systems, and/or create moisture conditions that may contribute to future mold growth in or on new or existing structures. The extent and proximity of the work to clinical areas and/or air intakes will be considered. The PCRA form will be used to document infection prevention measures to be implemented under these conditions. Education reviewing infection prevention measures shall be provided to contractors and vendors. Maintenance Activities Facilities and maintenance staff will assess the scope of work and the location required for work performance. A written copy of the PCRA is not required for projects determined by Facilities to be Class I or II unless indicated for other safety categories. For Class III or IV projects, a written PCRA must be completed (see Safety Policy: Pre-Construction Risk Assessment). Precautions will be communicated to both project workers and staff members of the immediate work area. The PCRA must be completed and precautions put into place by the manager overseeing the work prior to the start of work. In emergency situations where measures must be taken for the safety of patients or others, Facilities will proceed with necessary work without a PCRA and use reasonable measures to protect all persons and structures in the area from exposure to contaminated water, dust, or debris. EIP will be notified of emergency situations that, in the judgement of the Facilities or Project Manager, may present an infection risk to patients, visitors, or staff. EIP or Environmental Health & Safety (EH&S) may modify requirements of thepcra based on patient and employee safety needs. Any modification does not relieve the contractor or vendor of compliance with proper control procedures.
Page 3 of 6 EIP or Environmental Health & Safety have the authority to stop work immediately should a safety or health violation be observed during work performance. Prior to any construction or renovation, any sharps, medical waste or contamination of blood or body fluids in the construction space will be removed or cleaned. III. DEFINITIONS: See Appendix B: PCRA Matrix for Determining Infection Risk Class IV. PROCEDURE RESPONSIBLE PERSON(S)/DEPTS Planning Project Manager, EIP Project Manager Project Manager, PCRA Team Project Manager or Contractor PROCEDURE-Construction & Renovation Project Manager notifies EIP of any construction or renovation projects in clinical and clinical support areas during design development to allow incorporation of EIP recommendations into design planning. (See Appendix A: Design Development Considerations) Project Manager assesses project and determines appropriate PCRA team members. If project determined to be Class III or IV, include EIP in PCRA team. Project Manager assembles PCRA team prior to work starting. Using the PCRA form, the team will make safety and infection prevention recommendations as indicated by scope of project. Provide education to all workers, contractors or vendors performing construction or renovation activities. Education may be provided by the Contractor but must include the infection prevention elements of the PCRA. Basic rationale for these measures (may use Appendix C or D) Party providing the education is responsible for documentation. Provide copies for Project Manager s project files. Project Manager, EVS If project is Class III or IV, the Project Manager may start work when: All sharps & medical waste have been removed Visible blood or body fluids in the area have been cleaned PCRA form has been completed by the PCRA team and all
Page 4 of 6 appropriate precautions have been instituted. If any necessary precautions cannot be instituted prior to the start of work, notify EIP. Project Manager, EIP Manager and staff of affected department Contractor, Facilities Planning & Maintenance The Project Manager will send a copy of the PCRA to EIP. The PCRA form must be available at the work site, in project files, and in the EIP Committee minutes. Once notified of work to be performed and precautions to be instituted at the PCRA team meeting, manager of the affected department will communicate this information to appropriate staff. Staff should be alert for precautions to be in place and provide support as needed to maintain precautions to maximize safety for all. For projects lasting longer than one day, perform a routine inspection of PCRA measures to ensure compliance. Respond to any reports of breeches in safety measures; if necessary, contact EIP or Environmental Health & Safety for clarification or assistance (See Safety Policy: PCRA-Appendix B). EIP, Environmental Health & Safety Environmental Services, contractors/vendors Periodically check on projects to assess for compliance with appropriate safety measures. If appropriate PCRA measures are not in place, contact the Project Manager for resolution. If omissions in precautionary measures present an immediate danger to patients, employees or workers, EIP or EH & S Officer should notify workers to stop work and notify Project Manager of needed safety measures. Work may not recommence until needed measures are in place. Perform damp dusting on a regular basis to areas adjacent to construction activity to prevent the accumulation of dust. Vendors/contractors will provide clean-up of construction or maintenance area unless otherwise provided for in pre-construction specifications. EVS will provide support for Project Manager as deemed necessary. Facilities & Maintenance PROCEDURE-Maintenance Activities Maintenance worker will consider if work is Class I, II, III, or IV
Page 5 of 6 S taff Facilities & Maintenance staff, EIP (see Appendix B: PCRA Matrix for Determining Infection Risk Class) In general, Class I & II work generates little to no exposure of patients to dust, water or debris. In general, Class III or IV work presents a risk of exposure of patients to dust, water or debris. If work is considered to be Class I or II, no written PCRA for infection prevention is required. Worker proceeds with work minimizing exposure to dust, water or debris to patients and staff. If work is considered to be Class III or IV, Facilities will contact EIP prior to starting work to plan infection prevention measures using the PCRA form. For emergency situations: Facilities proceeds with work as needed to protect safety of persons in area and the environment Facilities notifies EIP as needed to assist in advising on infection risks to patients, visitors, or staff. V. EDUCATION: Appendix C and D or contractor provided educational program that contains required elements. VI. ATTACHMENTS Appendix A: Design Development Considerations Appendix B: PCRA Matrix for Determining Infection Risk Class Appendix C: Education (English) Appendix D: Education (Spanish) VII: RELATED POLICIES: Safety Policy: Pre-Construction Risk Assessment VII: REFERENCES
Page 6 of 6 California Code of Regulations, Title 22, Division 5, Chapter 1: General Acute Care Hospitals. CDC Guideline for Environmental Infection Control in Health-Care Facilities, 2003. American Institute of Architects, Guideline for Design and Construction of Hospitals and Health Care Facilities, 2006. APIC State of the Art Report: The Role of Infection Control during Construction in Health Care Facilities, 1999. Joint Commission for Hospital Accreditation: Environment of Care Standard VIII. AUTHOR: IX. APPROVALS Committee 11/21/2008 Performance Improvement Committee 12/10/2008 Medical Executive Committee 12/15/2008 Governing Body 12/16/2008