FACILITY NAME Number:

System Policy Manual Page:

Subject: Infection Control Risk Assessment Effective Date: 1/30/200X

for Use During Programming, Planning,
Design, Construction, & Maintenance

Resource: Infection Control Consortium, Approval: Medical Director,

Facilities Council and Infection Control, Facilities
Construction Department Management

Supersedes: Policy dated 12/12/200X Review Date:

I. POLICY

It is the policy of FACILITY NAME to provide the safest possible environment for patients,
associates, physicians, and visitors during the performance of programming, planning, design,
construction, and maintenance. FACILITY NAME will utilize the Infection Control Risk
Assessment methodology.

II. DEFINITIONS

1. Infection Control Risk Assessment (ICRA) a tool to assess the level of infection control risk in an
activity. The ICRA shall address, but not be limited to:

disruptions of essential services to patients, associates, and physicians

patient placement or relocation
placement of effective barriers to protect susceptible patients from airborne contaminants
air handling and ventilation needs in critical areas such as surgery and isolation room,
laboratories, and special exhaust systems
determination of the required numbers of airborne infection isolation or protective
environment rooms
protection of the domestic water system to limit waterborne pathogens like Legionella
protection of patients from construction project hazards such as planned or unplanned power
outages, demolition and movement of debris, managing changes in ventilation and water
systems, cleanup, certification, etc.
The FACILITY NAME facility is responsible for providing the ICRA. The design professional is
responsible for incorporating the specific construction-related requirements of the ICRA in the
contract documents, which shall require the constructor to implement these specific requirements
during construction. The constructor is responsible for implementing those specific requirements
during construction.

2. Utility Disruption an interruption of water, electric, gas (medical and natural), and vertical
transportation (elevators).
III. PROCEDURE

1. A multidisciplinary panel with expertise in infection control, risk management, facility design,
construction, ventilation, safety and epidemiology will conduct and document an ICRA during the
programming phase of every construction project and update it as the project proceeds through
planning, design, and construction.

2. Key elements to be addressed during programming include, but are not limited to: handwashing
facilities, ventilation, water systems, anterooms, traffic patterns, and storage facilities.

3. To determine the level of infection control activities required, perform the following 3 steps.

Step 1:
Using the following table, identify the Construction Activity Type (A-D)

Type A Inspection and Non-Invasive Activities

Includes, but is not limited to:
removal of ceiling tiles for visual inspection limited to 1 tile per 50 square feet
painting (but not sanding)
wall covering, electrical trim work, minor plumbing, and activities which do not
generate dust or require cutting of walls or access to ceilings other than for visual
inspection
Type B Small scale, short duration activities that create minimal dust
Includes, but is not limited to:
installation of telephone and computer cabling
access to chase spaces
cutting of walls or ceiling where dust migration can be controlled
Type C Work that generates a moderate to high level of dust or requires demolition or
removal of any fixed building components or assemblies
sanding of wall for painting or wall covering
removal of floor coverings, ceiling tiles and casework
new wall construction
minor ductwork or electrical work above ceilings
major cabling activities
any activity which cannot be completed within a single work shift
Type D Major demolition and construction projects
Includes, but is not limited to:
activities which require consecutive work shifts
activities which require heavy demolition or removal of a complete ceiling system
new construction
 Step 2:
Using the following table, identify the Patient Risk Group that will be affected. If more than
one risk group will be affected, select the higher risk group:

GROUP 1 GROUP 2 GROUP 3 GROUP 4

LOWEST MEDIUM MEDIUM HIGH HIGHEST
1.) Office areas 1.) All patient care 1) Emergency Department 1) Transplant units
2.) areas not mentioned 2) Radiology/MRI 2) Operating Rooms; Sterile
Administration in groups 3 or 4 3) Post-anesthesia Care Unit Processing
3.) Public areas (example: Cardiac 4) Labor and Delivery 3) Labor and Delivery
Rehabilitation, 5) Newborn Nurseries Operating Rooms
Neurophysiology) 6) Pediatrics 4) Intensive Care Units
2.) Admission 7) Nuclear Medicine 5) Cardiovascular Recovery
3.) Outpatient areas 8) PT tank areas 6) Cardiac Catheterization &
9) Kitchen Angiography Areas
10) Echocardiography 7) Outpatient chemotherapy
11) Laboratories areas
12) Diagnostic Imaging 8) Dialysis
13) Respiratory Therapy 9) Oncology
10) All endoscopy areas
11) Pharmacy Admixture
12) Special Procedures
13) HIV Unit

Step 3:
Match the Patient Risk Group (1, 2, 3, 4) with the planned Construction Activity Type
(A, B, C, D) on the following Infection Control Matrix to determine the Class of Infection
Control Procedures (I, II, III, IV).

CONSTRUCTION ACTIVITY TYPE

TYPE TYPE TYPE TYPE
PATIENT RISK GROUP A B C D
Group 1 Lowest I II II III/IV
Group 2 Medium I II III IV
Group 3 Medium High I III III/IV IV
Group 4 Highest III III/IV III/IV IV
Note: Infection Control approval will be required when the Construction Project Activity Type and the
Patient Risk Group indicate that Class III or Class IV infection control procedures are necessary.
 Infection Control Procedures
Class I Execute work by method to limit raising dust from
construction
Ceiling tiles: Immediately replace tiles displaced
for visual inspection
Traffic: Visitor traffic routes should limit contact
with patients
Maintain manpower and equipment including dust
mops, brooms, buckets and clean wiping rags for
cleaning fine dust from floors and other surfaces on
adjacent occupied areas.
Class II Water: mist work surfaces when cutting
in addition HVAC: Air vents blocked and sealed before starting
to points Monitor need to change or clean filters during
for Class I construction
above: Area contained to 1 room with walls from floor to
ceiling. Close door and duct tape frames and door
Debris: covered, sealed and taped shut during
transport
No elevators used for debris removal
Contractor will clean up dust tracked outside
construction area immediately, using HEPA vacuum
or damp mop.
Transportation route or storage for clean supplies not
near contaminated materials
Traffic: Patient movement: Limit exposure of
patients to construction
Utility Disruption: Schedule interruptions during
low activity
Dust: wet-mop and place adhesive door mats at
entrance. Mats shall be changed daily or more
frequently, if necessary.
Holes in walls not exposed > 4 hours. Cover if
longer time period.
Ceiling: access panels without barriers must be
closed when unattended
Ceiling Tiles, porous: remove and replace if wet
Ceiling Tiles, non-porous: remove, clean with dilute
hypochlorite or other approved cleaning solution and
dry before replacement
Class III Consult Infection Control
in addition Educate staff regarding risks
to points Examine design of operational laundry/trash chutes
for for potential transmission
Classes Dust Minimization: partitions must be installed
above: prior to starting (including construction in ceilings).
These barriers, including those above ceilings, shall
be dust tight.
Debris: Chute for debris removal: HEPA-filtered
Transport debris during low activity period
Site thoroughly cleaned before patient admittance;
remove blockage of air vents and wet mop with
disinfectant
Barriers: Dampers closed temporarily to limit
circulation of contaminated air
Assure adjacent air filtering systems are functioning
Thoroughly clean new area before patient
admittance
Airtight plastic barrier from floor to ceiling or
drywall
Plastic seams must be sealed with duct tape
Remove barriers carefully to limit spread of
dust/dirt
Barriers considered debris at disposal
Ceiling: Openings from removed tiles covered in
plastic and sealed until replaced
HVAC: Bottom of outdoor air intakes serving
central system 6 feet above ground or 3 feet above
roof
Exhaust system above roof and 75 feet from air
intake
Maintain negative pressure in construction area
Block off all existing ventilation ducts within the
construction area. Method of capping ducts shall be
dust tight and withstand airflow.
Class IV Consult Infection Control
In Relocate patients to area remote from construction
addition to areas
points for OR and Delivery Room: air supply from ceiling
Classes outlets near center of work area. Returns (at least 2
above: and far apart as feasible) near floor
Isolation Negative pressure for airborne isolation
Rooms Minimum of 12 air changes/hour
Exhaust to outside or recirculated after HEPA
filtration
Separate toilet, bathtub (or shower) and sink
Adequate room for handwashing, gowning, and
storage of clean and soiled materials
2. PERFORMANCE REQUIREMENTS
Increase air filter change frequency
Fresh air intakes 25 feet from exhaust outlets of vent
system, combustion equipment stacks,
medical/surgical vacuum system, plumbing vents, or
area near vehicular exhaust or other fumes
Vent system cleaned and balanced after completion
of construction
Carpet: Avoid in clinical areas (including hallways)
Never in areas of frequent spillage or heavy soilage
(OR, ICU, Lab)
Water: Mains, branch mains, risers, and branches to
a group of fixtures have stop valves
No built-in soap dispensers
Adequate room for single-use paper towel dispensers
and waste disposal
Water lines flushed at site And adjacent areas before
patient occupation
Temperatures checked before patient admittance
Floor drains should be avoided
Obtain potable water when needed
Sinks: Easily accessible; nearby surfaces are non-
porous to resist fungal growth
Cooling Tower, New: Direct tower drift away from
air intake system. Operational: Drift eliminators
present and biocides used regularly
Control Cube: When access panels are opened or
new openings are made in existing ceilings in
occupied areas use a Control Cube or provide a
plastic enclosure around the ladder sealing off
opening, fitted tight to the ceiling and floor.
Water: No floor drains
Sinks: Foot, knee, or sensor control units when risk
of touch contamination (e.g., OR)
Air in OR: Must have at least 90% filters
Bone Marrow Transplant (BMT) or Protected
Environment Room: HEPA filtered
Positive pressure for BMT
Anteroom(s) recommended (at least 1 room that can
be made negative pressure for patient with an
airborne infection)
Best air flow:
Hallwayanteroompatient room
HEPA-filtered
Rooms well-sealed
 A. Infection control is critical in all areas of all facilities. Construction activities causing disturbance
of existing dust, or creating new dust, must be conducted within ventilation-controlled areas that
minimize the flow of airborne particles into patient areas.

B. FACILITY NAME requires any subcontractor, sub-subcontractors, material suppliers, vendors,

employees, or agents to be bound by these same requirements. Before any construction on site
begins, the Contractors on-site management team shall attend a mandatory education program
approved by Infection Control, for instruction on precautions to be taken.

C. It should be determined whether the construction area uses fresh/outside or recirculated air; filters
should be added or return vents covered as needed with filter material or plastic. Air must flow
from clean to dirty areas.

D. The air within the construction area must be negative with respect to surrounding areas and with
no disruption of air systems of adjacent areas. Constant negative pressure within the zone should
be monitored with an alarmed device, which must be maintained and monitored by construction
personnel. Exhaust from construction air should be directed outside with no recirculation if
possible. If the exhaust must tie into a recirculated air system, a pre-filter and high efficiency
filter (95%) should be used before exhaust to prevent contamination of the ducts. Fans should be
turned off before opening ductwork and necessary interruptions (e.g., fire drills) should be
planned for to minimize risk. High efficiency filter air machines shall provide airflow out of
construction areas to create negative pressure at barricade entrances with doors fully open. HEPA
equipped air filtration machines shall be connected to normal power hooked to a single switch for
emergency shutoff and shall run continuously.

E. The Project Manager or Infection Control Department may modify performance requirements for
certain activities. Any modification made by FACILITY NAMEs personnel does not relieve the
contractor of compliance with proper infection control procedures.
3. SUBMITTALS

A. The contractor shall submit a report outlining the infection control procedures, including location
and details of barrier.

B. Product Data: The contractor shall submit product data for products used in the project.

4. QUALITY CONTROL

FACILITY NAMEs Infection Control Department will monitor biological counts in vicinity of
construction work as appropriate. Whenever safe levels are exceeded, contractor will be notified to
correct conditions immediately.

1. All work shall be stopped on the project whenever a hazardous infection control deficiency
exists.
2. Contractor shall take immediate action to correct all deficiencies.
3. Failure of Contractor to correct such deficiencies will result in corrective action taken and
deduction of all costs from the contract. No work will proceed until corrective action is
completed.

5. INFECTION CONTROL PERMIT

 A. An Infection Control Permit is required for Class III or higher procedures and any activity in a
Group 4 Infection Control Group. Refer to shaded area on Construction Activity/Infection
Control Matrix.

B. When required, obtain Infection Control Permit from the Infection Control Department before
beginning any demolition or construction work.

C. Permit to be displayed at entrance to work area during entire construction period.

D. Return permit at completion of work.

6. PRODUCTS and MATERIALS

A. Sheet Plastic: Fire retardant polystyrene, 6-mil thickness.

B. Barrier Doors: Solid core wood in metal frame, painted.

C. High Efficiency Particulate Air-Equipped filtration machine

D. Exhaust Hoses: Heavy duty, flexible steel reinforced; Ventilation Blower Hose

E. Adhesive Walk-Off Mats: Provide minimum size mats of 24 inches x 36 inches

F. Disinfectant: Hospital-approved disinfectant or equivalent product.

G. Portable Ceiling Access Module

7. BARRIERS

A. Closed door with masking tape applied over the frame and door is acceptable for projects that can
be contained in a single room.

B. Construction, demolition or reconstruction not capable of containment within a single room must
have the following barriers erected.

1. Airtight plastic barrier that extends from floor to ceiling. Seams must be sealed with duct tape
to prevent dust and debris from escaping.
2. Drywall barriers erected with joints covered or sealed to prevent dust and debris from
escaping.
3. Seal all penetrations in existing barrier airtight.
4. Barriers at penetration of ceiling envelopes, chases and ceiling spaces to stop movement of
air and debris.
5. Anteroom or double entrance openings that allow workers to remove protective clothing or
vacuum off existing clothing.
6. At elevator shafts or stairways within the field of construction.
7. Overlapping flap minimum 2 feet wide at polyethylene enclosures for personnel access.

8. INFECTION CONTROL PROCEDURES

 GENERAL

A. Maintain manpower and equipment including dust mops, wet mops, brooms, buckets and clean
wiping rags for cleaning fine dust from floors in adjacent occupied areas.

B. Contain work areas outside of construction barriers, including spaces above ceilings, with full
height polyethylene sheet barrier, tightly taped.

C. The contractor will clean up dust tracked outside of construction area immediately.

RESPONSIBLITIES: GENERAL and by ACTIVITY CLASS

A. The Contractor is responsible for obtaining the Infection Control Permit from the FACILITY
NAME sites Infection Control Department prior to commencing construction.

B. FACILITY NAMEs Construction Department and sites Infection Control Department will
evaluate every work order. They reserve the right to add requirements to a project on an
individual basis.

C. The sites Infection Control Department will make periodic visits to work site to ensure
compliance of policy.

ENVIRONMENTAL MONITORING

A. Contractor is responsible for maintaining equipment and replacement of High Efficiency

Particulate Air filters and other filters in accordance with manufacturers recommendations.

B. FACILITY NAMEs Project Manager and Infection Control Department will perform field
inspection and testing.

C. FACILITY NAMEs Project Manager will confirm specified air velocity whenever barricades are
erected or modified.

D. FACILITY NAME personnel will monitor air quality throughout project as needed.

ENFORCEMENT

A. For breach of this infection control policy FACILITY NAME will stop the work of the project
and the contractor shall pay for all associated costs incurred by FACILITY NAME as well as for
correction for the work.

B. FACILITY NAMEs Project Manager will record the following:

1. Document each violation with photographs

2. Extract Contractor or Department information from the work log.
3. Maintain a record of all infection control violations.

C. Violations of infection control policies may affect status as a contractor for bidding future work.

IV. CROSS REFERENCES

IV. EXHIBITS/ATTACHMENTS
 INFECTION CONTROL RISK ASSESSMENT
SITE INSPECTION

Project :________________________Building/Location__________________Floor________

Date: ______________ Time: _____________ Inspector ___________________ Title _____________

Items to Check YES NO N/A COMMENTS FOLLOW-UP

PROCEDURE

ICRA completed and filed

on site.
ICRA permit for Class III or higher
construction activity displayed at
entrance to work.
ICRA permit returned to safety following
completion of work.
CONSTRUCTION PERFORMANCE REQUIREMENTS SUBMIT-TALS

Contractors infection control measures

report on file with safety department.

Contractor has submitted product data

for job site materials.

Construction creating dust is conducted

within ventilation controlled areas to
minimize flow of airborne particles.
Contractors on site management team
have attended infection control training.

Air flows from clean to dirty areas.

All air vents (return, and exhaust) are

covered

The air within the construction area is

negative with respect to surrounding
areas.

Contractor is maintaining equipment and

replacing high efficiency air filters.

Construction work complies with all

requirements of Class III & IV infection
control procedures.
QUALITY CONTROL

Work has been stopped on the project

for a hazardous infection control
deficiency.

The contractor has taken immediate

action to correct all deficiencies.
Corrective action has been taken on the
contractor. No work has proceeded until
the corrective action is in place.
Project :________________________Building/Location__________________Floor________

Date: ______________ Time: _____________ Inspector ___________________ Title _____________

TOPIC YES NO N/A COMMENTS FOLLOW-UP

BARRIERS

Airtight plastic extends from floor

to ceiling.

Drywall barriers erected with joints

covered or sealed to prevent dust
from escaping.

All penetrations in existing barriers

are sealed air tight at ceiling
envelopes etc.

Anterooms are in place that allows

workers to remove protective
clothing.
ENFORCEMENT

Air quality is monitored and

recorded.

Infection control violations are

being recorded.

Site inspection is monitored, evaluated, and logged twice a month by the Project Manager or
Infection Control together with Public Safety, and the General Contractor. FACILITY NAMEs
Project Manager and Infection Control Department will perform any testing requirements.

ADDITIONAL COMMENTS: __________________________________________________

______________________________________________________________________

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____________________________________________________________________________________
 FACILITY NAME Hospital
Infection Control Risk Assessment
Construction and Facility Maintenance

Initial Risk Assessment Checklist

Projected Start Date: _________________________ Projected End Date: _________________________

Project Number/Name: __________________________________________________________________

Project Location: _______________________________________________________________________

Brief Scope of Work: ___________________________________________________________________

Assessed By: __________________________________________________________________________

_____________________________________________________________________________________

Rating Summary: (Refer to IC Matrix below)

Class of Precautions: ____ Construction Activity: A, B, C, D; Risk Level: Low, Medium, High, Highest

IC Matrix-Class of Precautions
Type A Type B Type C Type D
Low Risk Group III/IV
Medium Risk Group III IV
High Risk Group III/IV IV
Highest Risk Group III/IV III/IV IV

Project Duration:
[] Short-term Project: Project Duration of a single work shift or less than 24 hours
[] Long-term Project: Project duration greater than 24 hours
[] Large Scale Project: Project which may result in significant interruption

ection Control Precautions by Class

Coordination of activities in these areas is to occur before the project is started. The project
manager is responsible to coordinate area activities with the area/unit manager and infection
control. Items not checked are determined to be not applicable.

ss I
[] Immediate area is to be unoccupied.
[] Close doors to adjacent areas and patient care rooms prior to activity
[] Immediately replace any ceiling tile removed for visual inspection
[] Local plastic non-rigid containment barrier tightly sealed at ceiling, walls, and floor. A single slit entrance
w/closed flap or zippered opening may be used for access.
[] Seal unused doors with duct tape and/or plastic sheeting.
[] Debris and dust are promptly cleaned up and disposed of.
[] Mist or vacuum work surfaces while cutting to minimize dust.
Class II
[] Class I requirements plus
[] If hard barrier is required, complete barrier before construction/facility maintenance activity.
[] Block off or seal air vents.
[] Negative airflow with HEPA filter, filter exhaust directly to outside or tied into return air system.
[] Contain construction debris in tightly covered containers. Establish routes and times for disposal.
[] Adhesive walk-off mats to be placed immediately inside & outside of containment areas.
[] Wet mop and/or vacuum (HEPA-filtered) surfaces at the end of the shift.

Class III
[] Class I and II requirements plus
[] Rigid floor to ceiling barriers required w/sealed joints.
[] Isolate HVAC system.
[] Negative airflow with HEPA filter, filter exhaust directly to outside or tied into return air system.
[] All personnel entering work site must wear jump suit and shoe covers.
[] Seal holes, pipes, conduits and punctures.
[] At the end of project, hang temporary plastic non-rigid barrier to remove construction materials and rigid
barriers, to minimize dispersion of dust.

Class IV
[] Class I, II, and III plus
[] Construct ante-room.
[] All personnel must wear jump suit, shoe covers, mask, and hair cover to enter or travel through the clean/sterile
area. (Items are removed, left in the anteroom and put on again when the worker leaves the work area)
[] If sterile/invasive procedure area is entered, tools must be damp-wiped or bagged prior to entering and exiting
work area. Debris cart must be damp-wiped prior to entering and exiting work area.
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[] Additional Infection Control related training required.
[] Risk Assessment posted outside activity area.
[] Additional Infection Control measures required for specific circumstances. Refer to System Policy;
Infection Control Measures for Use During Facilities Maintenance & Construction.

Special Notes:
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Infection Control Professional Project Manager
_______________________________________ _____________________________________________
Date Date
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[] Infection Control [] Facilities [] Project Site [] Unit/Department Manager