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Infection Control HVAC

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Infection Control HVAC

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    1. Infection Control & HVAC Presented to Puget Sound Chapter ASHRAE May 12, 2004 Good evening. I see a few folks in the audience that know me, and have worked on projects with me in the past. For those who dont know me, I worked for NBBJs Seattle Office for 33 years as a health care architect and medical planner. I resigned from NBBJ the end of April 2002 and started my own business, ICRA Design Consultants LLC. My primary service is providing health care facility planning and design services for Infection Control Risk Assessment teams. In addition, I provide medical planning services, and am also working with another company in the field of distressed exterior envelope remediation. For those that might be wondering, the slide background used is a view through a microscope of an Aspergillus pod releasing spores. Aspergillus spores range in size from 2 to 5 microns.Good evening. I see a few folks in the audience that know me, and have worked on projects with me in the past. For those who dont know me, I worked for NBBJs Seattle Office for 33 years as a health care architect and medical planner. I resigned from NBBJ the end of April 2002 and started my own business, ICRA Design Consultants LLC. My primary service is providing health care facility planning and design services for Infection Control Risk Assessment teams. In addition, I provide medical planning services, and am also working with another company in the field of distressed exterior envelope remediation. For those that might be wondering, the slide background used is a view through a microscope of an Aspergillus pod releasing spores. Aspergillus spores range in size from 2 to 5 microns.

    2. Why ICRA The New Guidelines ASHRAEs New Design Manual The ICRA Team and the HVAC Engineers Role. ICRA Documentation Infection Control is About More Than Construction Here's a list of the subjects I plan to cover this evening. I've given myself about 45 minutes to present, and will then be open to questions. If you prefer to ask questions during the presentation, I'll leave that up to you. Here's a list of the subjects I plan to cover this evening. I've given myself about 45 minutes to present, and will then be open to questions. If you prefer to ask questions during the presentation, I'll leave that up to you.

    3. Why ICRA? At the 1986 ASHE PDC in San Antonio, Texas, an engineer from CDC warned about the dangers of mold spores in the dust above the ceilings and legionella bacteria in the water. The 1996-97 edition of the AIA Guidelines included the first requirement for ICRA. The 2001 edition of the AIA Guidelines greatly expanded on the ICRA requirements. JCAHOs Environment of Care Standard that went into effect January of 2002 required a proactive assessment prior to construction renovation projects. In June 2003, following three years of drafts, reviews and revisions, the CDC released its Guidelines for Environmental Infection Control in Health-Care Facilities. JCAHOs 2004 Environment of Care manual makes reference to a Preconstruction Risk Assessment that some are referring to as the PCRAJCAHOs 2004 Environment of Care manual makes reference to a Preconstruction Risk Assessment that some are referring to as the PCRA

    4. There are ~5,500 hospitals in the US ~ 2.1 Million nosocomial (hospital acquired) infections annually In 2000 103,000 deaths from nosocomial infections Estimate of $3 Billion annually in cost to health care industry Estimate ~5,000 of the deaths are related to construction. Any of you that have been to an ASHE conference in the last few years and attended one of Doug Erickson's presentations will have seen these statistics before. All of these are estimates, and they all come from the CDC.Any of you that have been to an ASHE conference in the last few years and attended one of Doug Erickson's presentations will have seen these statistics before. All of these are estimates, and they all come from the CDC.

    5. From a presentation on ICRA by Doug Erickson at the 2002 ASHE Annual Conference This chart basically says that for the airline industry to match the health care industry in what I'll term "the mortality of clients", the airline industry would have to experience 17 airliner crashes per week of which approximately 4 per month would have to do with construction/maintenance related issues.This chart basically says that for the airline industry to match the health care industry in what I'll term "the mortality of clients", the airline industry would have to experience 17 airliner crashes per week of which approximately 4 per month would have to do with construction/maintenance related issues.

    6. Fatal case in the making

    7. Aspergillus in Lung

    8. Your Brain on Aspergillus

    9. NEXT SLIDE IS COURIER JOURNAL 2 OF 3NEXT SLIDE IS COURIER JOURNAL 2 OF 3

    10. The New Guidelines 2001 AIA Guidelines for Design and Construction of Hospital and Health Care Facilities 2003 CDC Guidelines for Environmental Infection Control in Health-Care Facilities 2004 JCAHO Environment of Care Essentials for Health Care Fourth Edition These are the definitive guides or standards for the issue of infection control during construction. The Environment of Care manual from JCAHO shown on the right is the only JCAHO standard you need. While I was with NBBJ, they used to get the whole Comprehensive Accreditation Manual from JCAHO, which was a waste. The Environment of Care standard in that manual is the only portion that impacts health care facility design, and all you get is the standard. If you obtain the EC Essentials for Health Care shown here, you get al lot of explanatory data that is very helpful.These are the definitive guides or standards for the issue of infection control during construction. The Environment of Care manual from JCAHO shown on the right is the only JCAHO standard you need. While I was with NBBJ, they used to get the whole Comprehensive Accreditation Manual from JCAHO, which was a waste. The Environment of Care standard in that manual is the only portion that impacts health care facility design, and all you get is the standard. If you obtain the EC Essentials for Health Care shown here, you get al lot of explanatory data that is very helpful.

    11. 2001 AIA Guidelines Chapter 5 Construction Chapter 7 General Hospital 7.2.C Airborne Infection Isolation Rooms 7.2.D Protective Environment Rooms 7.31 Mechanical Standards considerable references to ASHRAE standards, but no reference to ICRA

    12. CDC Guidelines Part I. Background Information: Environmental Infection Control in Health-Care Facilities, Part C. Air Part II. Recommendations for Environmental Infection Control in Health-Care Facilities, Part C. Recommendations Air Part IV. Appendices, Appendix B. Air

    13. JCAHO EC Standards EC.7.10 The organization manages its utility risks. EC.8.30 The organization manages the design and building of the environment when it is renovated, altered, or newly created.

    14. ASHRAEs New Design Manual HVAC Design Manual for Hospitals and Clinics How many of you have using ASHRAE's new design manual for hospitals and clinics? I wasn't aware it existed until I read a review of it in the May issue of Health Facility Management Magazine. Yet it has been out since June of 2003.How many of you have using ASHRAE's new design manual for hospitals and clinics? I wasn't aware it existed until I read a review of it in the May issue of Health Facility Management Magazine. Yet it has been out since June of 2003.

    15. The guide includes chapters on facility descriptions, an overview of health care HVAC, HVAC systems, existing facility design consideration, cooling plants, space and process heating systems, air handling and distribution systems, controls and instrumentation, life safety and fire protection, room design, clinics and other health care facilities, operation and maintenance, commissioning for hospitals and energy efficient design and conservation of energy resources. The Manual has 16 chapters, and while I have yet to see a copy, let alone read it, from the description is seems to cover what needs to be covered.The Manual has 16 chapters, and while I have yet to see a copy, let alone read it, from the description is seems to cover what needs to be covered.

    16. In addition, appendices are included on managing construction and renovation to reduce risk in health care facilities, disaster readiness, load calculations and equipment heat gains, infection control issues, life cycle cost analysis, ventilation trends, power quality issues, sample control strategies and operating room air distribution. I am curious why infection control issues were relegated to the appendix.I am curious why infection control issues were relegated to the appendix.

    17. Chapter 12: Room Design On negative air pressure, as is required for Airborne Infectious Isolation Rooms: Through dilution, a 500 cubic feet anteroom (for example) with an AVM of 50 cubic feet would experience a 90 percent reduction in the transmission of contaminated air to and from the isolation room. An anteroom is recommended as a means of controlling airborne contaminant concentration via containment and dilution of the migrating air. Chapter 12, on Room Design, covers among other subjects, negative air pressure as is required for Airborne Infectious Isolation or AII rooms. The quote here comes from the review in Healthcare Facility Management Magazine. The BLUE text highlights a portion of the discussion on negative pressure that I found interesting in t hat it recommends ante rooms. AVM = Air Volume MigrationChapter 12, on Room Design, covers among other subjects, negative air pressure as is required for Airborne Infectious Isolation or AII rooms. The quote here comes from the review in Healthcare Facility Management Magazine. The BLUE text highlights a portion of the discussion on negative pressure that I found interesting in t hat it recommends ante rooms. AVM = Air Volume Migration

    18. In Contrast: AIA Guidelines Section: 7.2.C Airborne Infectious Isolation Rooms does not require anterooms. The requirement for an anteroom was dropped in the 1996-97 edition of the Guidelines on the basis of a study. CDC Guideline: similar to AIA, but does recommend an anteroom for isolation of patients with VHF and smallpox. JCAHO EC Standard: No reference to anterooms Interestingly enough, the ASHRAE recommendation of ante rooms is in contrast to the AIA Guidelines lack of a requirement for anterooms. Sometime prior to 1996 a study was done the result of which resulted in the removal of ante room requirements from the AIA Guidelines. My attempts at obtaining a copy of that report have been fruitless. Ive been told by Doug Erickson who is on the Facility Guidelines Institute that anterooms may be back in the 2005 Guidelines.Interestingly enough, the ASHRAE recommendation of ante rooms is in contrast to the AIA Guidelines lack of a requirement for anterooms. Sometime prior to 1996 a study was done the result of which resulted in the removal of ante room requirements from the AIA Guidelines. My attempts at obtaining a copy of that report have been fruitless. Ive been told by Doug Erickson who is on the Facility Guidelines Institute that anterooms may be back in the 2005 Guidelines.

    19. In Comparison: Project ER One Project ER One was conceived as an effort to assemble, develop, study, and disseminate a body of information on ED design concepts and features that could be used in the design of new ED facilities or the retrofitting of existing facilities, enabling them to effectively cope with a surge of patients during a mass medical crisis. Infection control and isolation can be compromised when the door from the isolated patient's room is opened. Therefore, Ante rooms or vestibules at entry to ED isolation rooms are desirable. Project ER One at Washington Central Hospital in Washington, D.C. is an attempt to design an "all risks ready" ER that can respond to a mass medical crisis such as a bioterrorism incident. Phase 1 of Project ER One produced a large amount of recommendations, one of which was to provide ante rooms on the isolation room in an Emergency department. To the best of my knowledge, an ante room for the ER isolation room has never been part of the AIA guidelines.Project ER One at Washington Central Hospital in Washington, D.C. is an attempt to design an "all risks ready" ER that can respond to a mass medical crisis such as a bioterrorism incident. Phase 1 of Project ER One produced a large amount of recommendations, one of which was to provide ante rooms on the isolation room in an Emergency department. To the best of my knowledge, an ante room for the ER isolation room has never been part of the AIA guidelines.

    20. In Comparison: Infection Control Association of South Africa VHF Unit

    21. Chapter 13: Clinics and Other Healthcare Facilities On Operating Rooms in the Outpatient Setting: [Operating rooms] may not be as large, nor contain as much equipment, as the hospital-based equivalent. They are identical with respect to the ventilation requirements. In Chapter 13 of the ASHRAE design manual there is a statement relative to operating rooms in the outpatient setting that I take issue with. This statement, again from a quote in the HFM Magazine article states, .... In Chapter 13 of the ASHRAE design manual there is a statement relative to operating rooms in the outpatient setting that I take issue with. This statement, again from a quote in the HFM Magazine article states, ....

    22. Operating Room Size The technology which is moving surgical procedures from the inpatient to outpatient arena must be accommodated in the outpatient OR. Room sizes therefore tend to mimic the inpatient OR size. While that statement may be true for some of the minor outpatient operating rooms for some procedures such as dermatology, in general While that statement may be true for some of the minor outpatient operating rooms for some procedures such as dermatology, in general

    23. Chapter 15: Commissioning The chapter on commissioning describes the importance of accurate testing to assure the proper operation of complex HVAC systems common in hospitals. This chapter presents a framework for the commissioning process and outlines general requirements that can be adapted to health care facilities.

    24. In Comparison AIA Guidelines: 5.3 Commissioning Acceptance criteria for mechanical systems shall be specified. Crucial ventilation specifications for air balance and filtration shall be verified before owner acceptance. CDC Guidelines: C.II.G, Commission the HVAC system for newly constructed health-care facilities and renovated spaces before occupancy and use, with emphasis on ensuring proper ventilation for operating rooms, AII rooms, and PE areas. Category IC (AIA: 5.1; ASHRAE: 1-1996) JCAHO EC Standards: EC.8.30 included by reference to AIA Guidelines Category IC. Required by state or federal regulation, or representing an established association standard. (Note: Abbreviations for governing agencies and regulatory citations are listed, where appropriate. Recommendations from regulations adopted at state levels are also noted. Recommendations from AIA guidelines cite the appropriate sections of the standard). Category IC. Required by state or federal regulation, or representing an established association standard. (Note: Abbreviations for governing agencies and regulatory citations are listed, where appropriate. Recommendations from regulations adopted at state levels are also noted. Recommendations from AIA guidelines cite the appropriate sections of the standard).

    25. The ICRA Team and the HVAC engineers role

    26. ICRA Team AIA Guidelines: 5.1 Planning and Design, The ICRA shall be conducted by a panel with expertise in infection control, risk management, facility design, construction, ventilation, safety, and epidemiology.

    27. ICRA Team CDC Guidelines: Box 4 in Part 1

    28. ICRA Team JCAHO EC Essentials for Health Care: Reference to AIA Guidelines Published advise from experts During the design phase an interdisciplinary team, including safety and risk managers, contractor representatives, building engineers, direct care supervisors, IC staff, and others, must be involved.

    29. AMI Environmental Survey

    31. HVAC Engineers Role AIA Guidelines: 5.1 Planning and Design, the ICRA shall address but not be limited to the following key elements:(d) Air handling and ventilation needs in surgical services, airborne infection isolation and protective environment rooms, laboratories, local exhaust systems for hazardous agents, and other special areas. 5.3 Commissioning, Acceptance criteria for mechanical systems shall be specified.

    32. HVAC Engineers Role CDC Guidelines: Part 1, Table 7 CDC Guidelines are divided into four parts. Part 1 is the scientific background, Part 2 is the recommendations, Part 3 is references, and Part 4 is the appendices. Within the four parts, the acronym HVAC occurs 77 times.CDC Guidelines are divided into four parts. Part 1 is the scientific background, Part 2 is the recommendations, Part 3 is references, and Part 4 is the appendices. Within the four parts, the acronym HVAC occurs 77 times.

    33. CDC Guidelines: Part 1, Table 7

    34. CDC Guidelines: Part 1, Table 7

    35. NEW CONSTRUCTION

    38. ICRA Documentation There is no guideline that defines how an ICRA should be documented. Contractors typically indicate that the ICRA documentation they receive is inadequate The standard for documentation is the ICRA Matrix and an Infection Control Construction Permit. It doesnt require a team to complete these.

    39. Matrix - Type of Project This matrix is widely available to hospitals through APIC, ASHE, and other organizations. It's a good starting place, but it is not an ICRA. NEXT SLIDE IS TYPES OF PROJECTS MATRIX STEP 1 PART 2This matrix is widely available to hospitals through APIC, ASHE, and other organizations. It's a good starting place, but it is not an ICRA. NEXT SLIDE IS TYPES OF PROJECTS MATRIX STEP 1 PART 2

    40. Matrix - Type of Project This matrix needs to be modified to match the facility and patient mix of the particular institution that is producing an ICRA. I personally think that Type C and Tyoe D construction need some work on better defining what they are. These were developed by IC staff at a hospital in Texas NEXT SLIDE IS MATRIX STEP 2This matrix needs to be modified to match the facility and patient mix of the particular institution that is producing an ICRA. I personally think that Type C and Tyoe D construction need some work on better defining what they are. These were developed by IC staff at a hospital in Texas NEXT SLIDE IS MATRIX STEP 2

    41. Matrix Patient Risk Level This part of the matrix should reflect the exact public, staff, and patient population of the facility. Some non-patient areas such as Pharmacy and Laborities important to keep items dust free. There have been false lab readings because samples were contaminated with spores from dust. NEXT SLIDE IS MATRIX STEP 3This part of the matrix should reflect the exact public, staff, and patient population of the facility. Some non-patient areas such as Pharmacy and Laborities important to keep items dust free. There have been false lab readings because samples were contaminated with spores from dust. NEXT SLIDE IS MATRIX STEP 3

    42. Matrix Class of Precautions Here again, I have a problem with the designation of III/IV precautions. It should be either III or IV. NEXT SLIDE IS BREAK?Here again, I have a problem with the designation of III/IV precautions. It should be either III or IV. NEXT SLIDE IS BREAK?

    43. Purpose of Documentation From the viewpoint of the design and construction team members, the purpose of Infection Control Risk Assessment (ICRA) documentation is to identify, define and understand the relationship between at-risk patients and a construction project at all times during the course of the project. The nature of most construction projects requires that the ICRA documentation be regularly updated and or modified. The complexity of the documentation varies with the complexity of the construction project and the proximity of at-risk patients. NEXT SLIDE IS TYPICAL INADEQUATE DOCUMENTATIONNEXT SLIDE IS TYPICAL INADEQUATE DOCUMENTATION

    44. Minimum Basic Documents for Any Class III or IV ICRA ICRA Matrix check list Location of base-line monitoring readings Location of at-risk patients color coded At-risk patient traffic patterns color coded Other traffic staff, visitors, supplies, etc. Location of vertical openings and horizontal connections paths for dust migration Location of all existing rated walls Specifications IC Permit and construction period check list.

    45. At-Risk Patient Populations

    46. At-Risk Patient Traffic

    47. Vertical Openings & Horizontal Connections

    48. Base-Line Monitoring Plans

    49. Infection Control is About More Than Construction ICRA tends to be thought of as being oriented toward construction and renovation projects Clean air is a full time necessity in health care facilities Hospital preparedness for mass casualty incidents such as bioterrorism

    50. An Aerotech/P&K IAQ Tech Tip Microbial Fact: Researchers in Hong Kong have discovered how the virus that causes SARS spread throughout an apartment building and into other surrounding structures. The study, recently published in The New England Journal of Medicine, found that the virus traveled in aerosolized water droplets. The researchers recreated the drainage system of the building and found that powerful exhaust fans carried aerosols from the first infected persons bathroom drain to other bathrooms. Aerotech Laboratories, Inc. and P&K Microbiology Services, Inc., are teaming under the new name of Aerotech P&K Aerotech Laboratories, Inc. and P&K Microbiology Services, Inc., are teaming under the new name of Aerotech P&K

    51. UN: World Must Brace for Diseases According to a report in the Associated Press, the United Nations stated that the world must brace for future outbreaks of diseases like bird flu that leap the species barrier from animals to humans. Lessons learned from SARS, mad cow disease, and other illnesses have taught experts to be on the lookout for such outbreaks, but predicting the next epidemic will still be tough, said Dr. Francois Meslin, World Health Organization Coordinator for control of "zoonoses" - diseases that can cross species. Scientists also say the AIDS epidemic that emerged in the 1980s was the result of cross-species transmissions of another monkey virus - the simian immunodeficiency viruses, or SIV - to people several decades earlier. They based their theory on genetic analyses of the AIDS virus and similar viruses found in chimps.

    52. Future Considerations Zero Spore Facility? Andy Streifel at the University of Minnesota. Facility with all air HEPA filtered, and under positive pressure? National Air Filtration Association (NAFA) Position Statement on Bio-terrorism, The best protection for any building is to maintain positive pressure to the outside environment. Constant monitoring of IAQ pressure and contents? Floor Plenum throughout a facility for utility distribution and air supply or return?

    53. Doug Erickson, at 2002 ASHE Annual Convention A/E firms beware; you may be a contributor of stirring up environmental dust in our facilities. When doing preliminary field work to document the exact conditions of the existing facility, accessing ceiling cavities by the removal of ceiling tiles, opening of access panels in ceilings, chutes and shafts could be detrimental to high risk patient populations. Prior to any of this work taking place the field team needs to check in with facilities management to get a copy of the organizations infection control program for disrupting these building features.

    54. Questions?

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