By JANET HAAS, PhD, RN, CIC, Principal Consulting Epidemiologist, Innovative Infection Prevention
Facility managers, infection preventionists and contractors have been using infection control risk assessments (ICRA) for preventing infections related to healthcare construction and renovations since the 1996 Facilities Guideline Institute’s (FGI) Guidelines for Design and Construction of Healthcare Facilities recommended them. However, the application was quite different in the beginning and has evolved over the years. In the beginning, there was no matrix! Then a paper describing the matrix based on risk was presented by Kennedy, Barnard and Hackett at the Association for Professionals in Infection Control and Epidemiology (APIC) conference in 1996, and the matrix was adopted as a helpful tool to implement the ICRA.
A New Precautions Matrix
Although the matrix has become a staple of infection prevention for construction and renovation, there were still some grey areas that were left open to individual interpretation. In some facilities, infection prevention and control were consulting for changing lightbulbs, and in others, they were the last to know a project was being planned. In many cases, the ICRA was limited to discussions of barriers during major construction rather than being a multidisciplinary process that encompassed design, construction and commissioning. In 2020 the American Society for Health Care Engineering (ASHE) convened a group of experts to update the ICRA guidelines and called it ICRA 2.0. The new matrix is available here.
Although the FGI Guidelines now include the ICRA process in the multidisciplinary planning and design processes, the ASHE ICRA 2.0 document focuses on the actual construction phase of projects. It’s important to remember that infection preventionists should be included with other stakeholders long before the construction begins.
ICRA to ICRA 2.0: What’s Changed?
The main changes from the original ICRA to the new ICRA 2.0 include more complete descriptions of the various categories in the matrix, which reduces guesswork for users. In the past, the ICRA matrix focused on construction. Now, routine maintenance and ‘refresh’ activities are included in the appropriate construction type descriptions. For example, routine activities such as fan shutdown, installation of new flooring, and controlled sanding activities are now included in the matrix.
ICRA 2.0 also includes an official step for assessing the impact of construction activities on surrounding areas. In addition to familiar concerns about dust, ventilation and pressurization; noise, vibration and impact to data, mechanical and medical gas systems are now also included. There are mitigation strategies listed that can be implemented based on the individual project needs.
The actual matrix now has five construction project types, compared to four in the prior version. This provides the ability to differentiate among types of larger construction projects.
- Class I continues to be for inspection activities. These activities don’t require an infection control permit or approval unless a facility’s policy requires one. An option would be to have a standing ICRA permit that outlines the safety requirements for various types of inspections. Contractors or facility staff would then have a reference for the requirements and could fax details of the project to infection prevention or environmental safety.
- Class II activities are now ONLY for maintenance, and not meant to be used for construction or renovation. The idea is to have a class of activities for standing practices. The class II activities don’t require infection control permits or approvals but do require workers to follow standing precautions and procedures approved by the organization.
- Class III activities require a permit and approval from infection control when more involved construction is taking place, such as in Type C activities. This is the first category for actual construction or demolition. It includes renovation of a single room, removal of pre-existing walls and includes work creating significant vibration or noise. It’s important to note that inspection and maintenance activities rise to class III when conducted in high and highest risk areas, but according to the new ASHE documents, they don’t require an infection control permit.
- Class IV always requires an infection control permit and approval. This class includes maintenance in the highest risk areas, and active construction or renovation in other areas. This class requires critical barriers to meet NFPA 241 requirements and requires continuous active monitoring of negative pressure in the construction area. Air must be HEPA filtered or discharged directly outside.
- Class V requires infection control permit and approval, NFPA 241 compliant barriers, negative pressure monitoring and HEPA filtration. In addition, class V requires the construction of an anteroom that is large enough for equipment staging, cart cleaning, and workers. Workers also must wear coveralls at all times in the work area and remove them prior to leaving the anteroom into the facility.
The guidance also lays out the management of environmental conditions such as sewage, mold, asbestos, gray water and black water. This is at a minimum construction category IV and could often be category V.
A Separate Table
Another difference in the ICRA is the separation of construction mitigation from completion requirements. There is now a separate table with more complete instructions for cleaning and removal of critical barriers as minimal requirements. It’s important to note that re-commissioning water that has not been used for prolonged periods is not included in this guidance. Flushing water systems may be required prior to opening or re-opening if legionella is a concern.
Key Takeaways
To sum things up, the ICRA 2.0 tool developed by ASHE provides an update with much more specificity than the original ICRA. You’ll find typical maintenance activities included, a more exhaustive listing of patient care environments, and distinctions between inspection, maintenance and construction activities. The update has guidance for the construction activities and type of area in which they will be carried out, as well as a checklist for the assessment of the impact on surrounding areas. Finally, there’s a separate section for minimum activities at the end of the project. These tools can help guide facilities staff, contractors and infection preventionists with varying levels of familiarity with healthcare construction safety requirements to reduce risks associated with construction for patients, staff and visitors.
To access the ICRA 2.0 form and permit from ASHE's website, click here.
To view our recorded webinar, click here: ICRA 2.0: The Evolution of Prevention Planning & Healthcare Construction.
Dr. Haas is Principal Consulting Epidemiologist at Innovative Infection Prevention and an associate editor of the American Journal of Infection Control (AJIC). She previously served as Director of Epidemiology at 3 academic medical centers, and as 2018 APIC President. Prior to beginning her nursing and infection prevention professional journey, Janet also worked as a Journeyman Millwright Mechanic and was a member of the Carpenter’s Union.
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