Hospital Renovation & Construction

[Guest guest]

Hospital Renovation & Construction

What They Didn't Tell You in IC 101

By Schraag

Phoenix,AZ

http://www.infectioncontroltoday.com/articles/641feat3.html

Expert consultant J. Streifel shares his ideas on thinking

outside the box of contemporary infection control practices during

construction and renovation projects.

J. Streifel, MPH, hospital environment specialist for the

University of Minnesota's department of environmental health and

safety, has worked on many clusters of aspergillosis worldwide, with

the majority of his investigations within the U.S. Streifel says he

sees, and is involved mostly with, outbreaks concerning

aspergillosis or some other form of mycosis. Over his 25 years of

experience with such outbreaks, he has learned of countless problem

areas that simply aren't included in published literature or today's

standard guidelines.

Environmental Sampling

It is often confusing when broaching the subject of environmental

sampling to distinguish what the proper protocol should be. Some

experts say it should be conducted regularly while others call it

overkill and senseless. The Centers for Disease Control and

Prevention (CDC)'s " Guidelines for Environmental Infection Control

in Health Care Facilities: Recommendations of CDC and the Healthcare

Infection Control Practices Advisory Committee (HICPAC) " does not

recommend regular environmental sampling. Streifel on the other

hand, who served as a technical expert on the development of the

Guidelines, takes a unique stance — especially at the onset of a

construction or renovation project.

" Generally when I go out and do an infection control risk

assessment, regardless if it is internal or external, the

institution is responsible for the mechanical function of its

facility, " he says. " It is very important to demonstrate prior to

the project; to make sure the ventilation is working in some

fashion. It is important to discover a ventilation deficiency before

the project begins. During this process a tool bag with a pressure

gauge and particle counter will help to discern the existing

conditions.

" We want to verify those protected environments are working properly

before we begin. Be it the operating room (OR) or a bone marrow

transplant (BMT) ward. People say, `Well we need to get a baseline.'

A lot of people unfortunately don't understand what a baseline is.

It depends on what kind of set-up you have, " Streifel

explains. " Most of the time, baseline airborne fungi or particle

levels are a reflection of the filtration efficiency and pressure. "

When you are validating a ventilation system, you shouldn't have to

culture, he says. " If you're going to do environmental surveillance,

bang for the buck is watching the pressure, not culturing for fungi.

You want to make sure your controls are working. When you have to

culture, such as after an outbreak, an epidemiological investigation

would be appropriate. We sample monthly. Some institutions do it

quarterly. With culturing, there is no standard method. CDC

Guidelines say that you don't do random culturing. We have been

sampling our hospital since the `60s. "

Since 1986, Streifel has cultured 10 locations throughout the

hospital, including the radiation therapy area, a variety of

transplant wards, oncology wards, the BMT unit, and the intensive

care unit (ICU). " We know the air handling service areas, " he adds.

Streifel currently is working on data that is fan-specific rather

than service-specific. He says most of today's publications cover

only service and do not mention the fans or filter efficiency. " It

is important to understand how well ventilation systems work and how

to interpret the data, " he states.

Streifel also points out that breathing zone ambient air may be

different from supply air from the supply air room diffuser and he

says this adds to the mystery of air sampling. " What's happening

around me might be different from what is coming in through the

diffuser. This is often affected by activity or pressure

differences, " he explains. " We saw that in our bone marrow

transplant ward. The diffuser air that was coming directly out of

the diffuser was zero particles and the ambient slightly away from

the air supplier was running 200 to 300; outside we were running

50,000. That's the kind a gradient that I want to see. You have to

look at clean, cleaner, and cleanest; a rank order analysis of your

data. If the air in the breathing zone is substantially higher than

the diffuser air, then the potential for local activity affecting

the particle counts is logical. "

Surface sampling, however, is dependent upon the situation,

according to Streifel. " I have worked on several problems in

neonatal ICU as well as burn patients where I felt the surface

sampling was more relevant — especially if the patients have

Aspergillus growing on the body rather than in the lung. I tend to

look at dust as being more the issue vs. if it is in the air. We use

surface contact plates for such investigations and as stated have

found implicating organisms in dust around computer equipment. "

Streifel concludes, " Most of the time when we culture we should

expect status quo demonstrating low counts, and occasionally we find

that so-called `burst'. The burst is due to some kind of

environmental disruption that causes it to be released into the

environment. "

Internal Considerations

Potential growth sites for outbreaks are common in nearly every nook

and cranny of hospitals. Streifel shares where some of those " hot

spots " are and how he has come to know where to look over the years.

" What I like to think we should think about is to try to minimize

the environmental sources, " he begins. " We find mold all the time in

buildings. Anyone who says they don't have mold in their building,

you have to look at them with a jaundiced eye, because buildings

leak; we would be naive to think that buildings don't. They all leak

or condense water somewhere. It is difficult to anticipate when in

order to make sure we have some protection, " he cautions. Streifel

says proactive involvement is important from medical staff to

facility managers with an ICP or safety specialist in between.

If a facility is depressurized — which Streifel says he has seen in

some hospitals — the building is sucking in outside air around the

air handling systems. When a building is pulling humidified air in

due to a ventilation imbalance, humidity condenses on walls or on

cool surfaces.

Streifel says he has seen problems with walkin coolers, for example.

He offers one such example from a research facility. " I saw pictures

of all this cardboard that was just covered with mold. They're

growing at cold temperatures, but they are there as an example of a

source. Are they harmful? Maybe their alternate life form (fungi are

heterophalic) could be harmful, so we eliminate those sources too

with best practice remediation. "

He offers another example, " What happened to us in 1994, we had a

contractor puncture the roof and cause a major leak, which collected

in the floor rails. Modern construction using sheetrock puts up

metal studs and on the floor they attach those metal studs to such a

floor rail. That rail is about two inches deep and holds water. When

we have leaks from whatever source, we sometimes end up with water

in that rail. It gets into the insulation which we put in for sound,

and it wicks up. This often creates an ideal growth environment with

the sheetrock paper as a food source for the natural fungi found

everywhere. During the roof leak, water accumulated in the walls of

an isolation room — which is negatively pressurized — which grew

mold, Aspergillus fumigatus, next to the hot water riser. This was

an example of the perfect environment for selection of a thermophile

which is capable of growing in the lungs.

" So those situations can happen in any facility. We have to

recognize the situation when water damage happens and know how to

deal with it. "

He continues with other flooding situations. " Many large building

sewer systems `burp' due to overloading the sewer systems with food

debris or when someone flushes cloth down a toilet. These items can

plug clean-out traps, and when building occupants keep flushing and

the water has no place to go, it burps out from another toilet. This

can happen anywhere.

When these situations happen, they can create little reservoirs of

mold if you don't dry it out quickly. So we should really strive to

do that. " When we replace flooring, one of the first things that

happens is they pull the coving. When you pull the coving, we have

found that — and this is nationwide — janitors have a tendency to

flood the floors when they scrub and strip the floors. That gets

underneath the coving if it's not integral. If the slab is on the

rock, which is a construction detail — one we like to avoid — water

wicks up and is trapped. We've found a situation in rooms where it

grew mold behind the coving and it even came up over the top. "

Streifel points out other reservoirs of fungal spores such as what

is found underneath some of the equipment on carpet that has not

been moved for long periods or when an ice machine is moved. He says

to expect to find mold behind it due to opportunity to grow from

water leaks.

" Workers must be careful, " he adds. " When preparing for a project,

we can allow workers to take things off the wall before barriers and

pressure control, but we want all the barriers up before you start

moving ceiling tile. That is when we need clean-to-dirty airflow in

place. Often we use the fans in the window blowing out and all

pressure conditions are working properly. "

Places, People, and Things

Streifel participates in two to three aspergillosis outbreak

investigations each year. " Maybe more, it just depends, " he

affirms. " This year, I have had three phone calls from neonatal ICUs

with skin infections, and I've been in a burn unit where several

patients had skin infections. "

As Streifel previously mentioned, in the neonatal and burn units the

aspergillosis infections sometimes are not pulmonary. He explains

that a premature baby's skin is " not fully intact " so it can serves

as a kind of growth media if contaminated by opportunistic fungi.

" One unit called me because the neonates were getting infections on

their backs. That tells you right there they could be contaminated

from the laundry. " One facility — an oncology unit — he visited said

they were getting skin infections. Coincidently, they were jack

hammering across from where they were storing the laundry. " You have

to think not only about where the patients live, but where the

supplies are stored. The nutrition department, the janitorial

services, and the laundry products go into hospital rooms

unquestioned. Often we don't even think about any issue with them.

Janitor closets are supposed to be somewhat clean; not totally

filthy. You shouldn't have mold growing in those closets and I have

seen mold growing in several janitor closets. Vigilance includes

inspecting and routinely cleaning those areas, " he advises.

The mechanical room in an operating room suite was another area he

used as an example. " Behind the autoclave flasher the walls were

covered with mold, " Streifel points out. " Should you be worried that

they are doing an orthopedic surgery on the other side? Of course.

But if you think about it, that room is under extreme negative

pressure because they're trying to get the heat out by design. It

would be unlikely, even with all this mold, for it to escape unless

that fan goes down. That mold will be exhausted to the outside. What

you worry about is when someone enters and disturbs the colony. The

person then becomes contaminated and is a potential vector.

" I visited another hospital last year in a construction preparation

process and there was this huge colony of yellow mold in a lab under

repair due to water damage. The colony was yellow and presumptive

Aspergillus. It was about 3 feet high by about 4 feet wide. You

could imagine a billion spores right there. What was remarkable

about it was there were two brooms beside it. Right there! I have to

ask, `Do you know what a fomite is?' The brooms could be taken to

other locations and distribute the spores there. "

Streifel says dish rooms should be included in special precautions

during construction due to the fact that they are a known humid

water source. The dish rooms should have about 50 air changes an

hour to remove the humidity, he advises. Also, if water damage has

occurred, the workers could carry the mold around the hospital.

" Laboratories should be high-risk areas because if one colony grows

on a plate, doctors think the patient has aspergillosis in their

blood and will begin treatment, " he warns. " Such growth can be a

false positive if the microbiology laboratory is contaminated. This

summer a project below the micro labs became a problem when a

construction worker punched a hole right through the lab floor when

he was hammer drilling. The lab is under negative pressure so it is

a risk area. Dust will migrate that way and contaminate a clinical

specimen.

" Vigilance is important to anticipate where patients go and what

they may be exposed to in their wanderings. The BMT patients are

some of the most confined, but other transplant patients are allowed

to exercise. This fact makes it important to conduct the best

infection control practices hospital-wide. "

External Considerations

Construction projects executed outside the building also are

important for infection control practitioners (ICPs) to evaluate and

take the appropriate precautions. Streifel has worked as a

consultant on projects nationwide involving the demolition of a

buildings close by the hospital.

" Often I am called and asked what they should worry about. Well,

when you think about demolishing a parking ramp, it is right next to

the hospital. Most of the problem would be concrete dust — until

they hit the dirt. Once they start moving dirt, you should become

concerned that they will create an aerosol of whatever kind of

fungal organism that is disturbed. Maybe some of them can grow in

lungs. So what we would do there, we make sure all the windows are

sealed on the immunocompromised wards or other at risk areas. At one

facility in the state of New York, we found the seals coming off the

windows in the immunocompromised patient ward. This was discovered

in the pre-construction risk assessment. "

Infiltration is an issue unless you have appropriate positive

pressure, Streifel points out. " The current guidelines for hospitals

specify .01 inch, which is from the American Institute of Architects

(AIA) 2001 edition of the Guidelines for Design and Construction of

Hospitals and Healthcare Facilities and the CDC Guidelines. If they

don't have that pressure, one worries that the wind direction will

cause contamination to infiltrate the room, especially if it has

leaky windows and a project is creating a dirt aerosol from

excavation outside the building. Making sure windows are sealed

protects and saves energy. "

He continues, " Making sure the filters are properly installed is

essential. It is difficult to think that I have found a large number

of hospital fan systems that don't seem to have their filters

properly installed. I looked at about 10 fans at a facility recently

and found that seven of eleven fans did not have a 70 percent

reduction in particles >05 microns in diameter. The rest were below

60 percent removal efficiency. We question if filters are properly

installed. If properly installed, we should see a 90 percent

particle reduction. "

When commercial construction is conducted near the healthcare

facility, Streifel says the hospital should certainly get involved

in the communication. He offers tips on what ICPs should watch for

when an external project is being done near their facility.

" Keep the streets clean, " he advises. " Keep the trucks away from any

air intake areas of the facility. There will be trucks coming and

going. They often sit and idle waiting to load or unload. Or a

compressor may be placed underneath an air intake. Avoid such

conditions due to the impact on the occupants regardless if it

involves infection control. The ICRA (infection control risk

assessment) team should expect there might be a utility

interruption. That interruption may affect the water or the

electricity, and contingencies should be pre-managed — especially

communication.

" As an additional thought, if there is a cooling tower in the

vicinity, the hospital should make sure they are checking for tower

chemicals on a regular basis. We ask they increase the surveillance

of the tower to ensure they are providing enough chemical to control

microbes. If you start excavating and digging in an area, you start

to release the soil and the soil will get into the cooling tower.

During such conditions, the dirt ups the chlorine demand or the

oxidant demand so that it will use up the chemicals much faster.

Under these circumstances the chemicals should control Legionella (a

soil microbe). I worked on one case where the construction workers

developed [an infection from] Legionella because of their proximity

to a contaminated tower. We know we have to maintain them and that

is where we should put our effort. "

External projects as far away as a mile and a half can affect a

facility's patients, as Streifel has found in past

investigations. " About 10 years ago, we had three intensive care

cardiac patients develop aspergillosis. We did the epidemiology,

found timelines associated with sampling, patient passes, and

maintenance, and tried to figure out what could be a source. We have

sampling data. That summer we had huge numbers of Aspergillus

fumigatus cultured from the outside air. In the times that we

sampled outside once a month, all of those had greater than 200 to

300 colony forming units of Aspergillus fumigatus per cubic meter

outside of the hospital. That level seemed unusual. Normally we see

2 to 20 cfu/m3, but rarely that large of a number.

" Across the river, about a mile and a half away, they were tearing

down grain elevators that summer. Was that a potential source? We do

climatological data also when we collect, so we get an idea of wind

direction. There are some indications that it could be. "

He continues, " I worked on a cluster of infections in Oregon. The

hospital was under negative pressure when I tested the outside

doors. They were excavating across the street, but I speculate that

probably once every three days, the wind was in the right direction

and blew the dirt toward the hospital. That is why these things are

so sporadic; it depends on the wind direction. "

Streifel offers several recommendations to protect from such

incidence:

Change the entrances of the building for external construction

Offer shift valet parking

Install covered/protected walkways

Someone should be watching the weather and watch several stations

Finally, he suggests utility tunnels remain protected. " Those

utility tunnels can be a significant, important source of mold

infiltration, " Streifel asserts. " If you're demolishing a building

and they are connected to a hospital that is a high rise, that warm

air in a building will rise. It pulls air from the bottom where the

utility tunnels are located. A utility tunnel can connect as a

conduit for construction aerosol to get into that tunnel then be

sucked toward the elevator shafts and distribute the aerosol through

the building. This has happened. I have seen clustering like this in

a couple of hospitals that were potentially associated with improper

air balance due to air coming in through utility tunnels. "

As Streifel repeatedly points out, " There are seemingly endless

permutations for Aspergillus sources. " Education, experience, and

often a little common sense can help fight against these infectious

clusters and make renovation and construction projects safer for

patients and healthcare facilities as a whole.

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Revised AIA Guidelines scheduled for release, to include educational

workshops

The American Institute of Architects (AIA) and the Facility

Guidelines Institute (FGI) has scheduled the release the 2006

edition of the Guidelines for Design and Construction of Health Care

Facilities for April 2006. The Guidelines are updated on a four-year

cycle by the multidisciplinary Health Guidelines Revision Committee

(HGRC).

Workshops will coincide with the release of the 2006 edition and are

designed for architects, engineers, facility managers, project

managers, and contractors. The two-day program features a lecture

format with open forums and question-and-answer sessions.

At the conclusion of the program, attendees will be able to:

Explain the underlying intent and current interpretation of existing

and newly revised text in the Guidelines

Identify, locate, and use the information relevant to a health

facility project quickly and easily

Discuss how a facility's state applies the Guidelines

Determine how the new Guidelines will affect the design and

construction of specialized patient care areas

The workshops are presented by the American Institute of Architects

Academy of Architecture for Health (AIA/AAH) and the American

Society for Healthcare Engineering (ASHE) of the American Hospital

Association (AHA). They will be held in four major U.S. cities and

will begin in June 2006. The registration fee includes a copy of the

2006 edition of the Guidelines. For more information on the

workshops, visit the AIA/AAH Web site at www.aia.org/aah. Details

and registration information will be posted online as it becomes

available.

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Additional External Considerations Concerning Aspergillus

Transmission

By Schraag

Cotton fibers contaminated with Aspergillus niger spores Photo

Credit: Photograph provided by S. Kay Obendorf, Cornell University

The source of Aspergillus and quantities required to produce

infection remain an issue of concern for hospital infection control

as many occurrences of the disease have not been linked to an

obvious source.1 One Cornell University study was conducted to aid

in understanding the mechanisms of retention of Aspergillus spores

on textiles.

" The purpose of the study was to use laboratory methodology to prove

that Aspergillus spores could hitchhike into a immunocompromised

patient's room by visitors and healthcare workers' clothing, "

explains Kay Obendorf, PhD, coauthor of the study and associate dean

for research and professor of textiles and apparel at Cornell

University.

Obendorf says during the study, she and then Cornell graduate

student Betsy Dart examined different textiles for their ability to

retain and release the spores. " You could easily see that different

textiles had different properties as far as holding and releasing

the spores. The size of the textile and the surface structure on

fibers and hair are just the right scale for holding these spores,

but not holding them so tightly that they won't be rereleased by

movement of the garment or the person in the room with the patient. "

The researchers found that fiber surface morphology and moisture

content are two of the main factors regulating the retention and

release of spores from fabrics. Furthermore, it was concluded that

the most unusual propensity for storage and release of spores was

seen in cotton fabrics because " the physical structure of cotton

allows the fiber to act as a storage device for spores, " the

researchers wrote.

" What we were trying to show is there needs to be some control in

the protocol related to clothing, " she points out; further

explaining, " You'll see people with booties and they're at the local

coffee shop still wearing their booties. Well, what are the booties

for? They are to protect the area of the patient from outside

contamination and here they are wearing the booties collecting all

of the spores from the outside and then they go back into the

medical isolation. This is worse than if they hadn't worn the

booties. "

" The idea of Betsy's work was to use this information to have more

strict protocols in place to deter these spores from hitchhiking

into a room that you have already cleaned with a HEPA filter. You

need to not re-contaminate the room that you've cleaned.

Anytime you have a patient where cross-contamination of bacteria or

spores that can come off of clothing and people's hair; that should

be considered in addition to the hands and gloves and things that

they wear. "

The researchers concluded that the best solution in the hospital

setting is to change into clean apparel and shoes in a holding area

prior to entering the isolation area. Obendorf also advises

facilities have their textiles cleaned inside the hospital rather

than using an outside source and exposing them to the outdoor

air. " Clean textiles transported through the outside air is an area

of contamination, " she affirms. " It just depends on what is in the

soil and what the wind conditions are. The humidity also is a factor

because humidity has an effect on retention and release of the

spores. So, all of these environmental things play a factor. "

Although hair was not specifically tested in this study, it is a

fiber and can be expected to follow the same physical

principles. " So, hair caps should also be worn in hospital isolation

areas, " the researchers concluded.

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Reference:

1. Dart, BL and Obendorf, SK. " Retention of Aspergillus Spores on

Textiles, " Performance of Protective Clothing: Issues and Priorities

for the 21st Century: Seventh Volume, ASTM STP 1386, C. N.

and N. W. Henry, Eds., American Society for Testing and Materials,

West Conshohocken, PA, 2000

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