Construction: A model program for

infection control compliance

Francine Kidd, RN, BSN, CIC,a Clark Buttner, BA,b and Amy B. Kressel, MDa,c
Cincinnati, Ohio

Issue: In the 21st century, one of the most challenging tasks for the infection control practitioner (ICP) is establishing collegiality
and trust with contractors, architects, maintenance and engineering personnel. We describe how an urban teaching hospital’s in-
fection control program cooperated with contractors during a large demolition, construction, and renovation project in order to
protect its large population of immunosuppressed patients.
Project: Most contractors are not accustomed to taking special precautions during demolition. Because of a previous Aspergillus
outbreak in our heart transplant population, we already had an established infection control (IC) training program for contractors.
We expanded and codified it in response to a major hospital renovation. The IC, in-house Design and Construction, and outside
contractors meet before the initiation of all major renovation projects to anticipate IC concerns and proactively plan for infection
control interventions. Now, all contractors and maintenance staff are required to receive IC training at the time of their employ-
ment. A hospital identification badge with attached sticker that indicates the IC training date is required. Infection Control Risk
Assessments (ICRA) are initiated by project managers and completed jointly with IC. The ICPs make rounds on all projects at least
weekly and large projects are visited daily. We established a team comprised of ICP, project manager, construction manager, and
area nurse manager to monitor and make recommendations for improvement continually during the project. Staff are educated
about construction so they can help monitor airflow and cleanliness.
Results: Our contractors are more compliant with our IC specifications since they now understand why we insist on them.
Through the years of major construction, the workers have jumped on the bandwagon. It is not unusual for construction or main-
tenance staff to contact IC for advice. There were four years of extensive construction without any hospital acquired Aspergillus
infections. In the 5th year, after a neighboring institution started demolition and new construction, we identified two possible nos-
ocomial infections and took immediate steps to make more corrections. There have been no further infections.
Lessons Learned: The IC compliance is based on trust, education, and on-going monitoring. Proactive education and collaboration
lead to long-term relationships, trust and patient safety.
Objective: This article describes how a large teaching hospital’s infection prevention program achieved compliance from contrac-
tors during a large renovation. (Am J Infect Control 2007;35:347-50.)

Immunosuppressed patients, such as organ trans-
plant recipients, and chemotherapy and burn patients,
are at high risk for hospital-acquired aspergillosis from
construction.1-6 If left undisturbed (as behind a wall),
Aspergillus is not a threat to the immunosuppressed.
Construction and renovation in hospitals often is asso-
ciated with dissemination of Aspergillus spores.3-6 Most
contractors are not accustomed to taking special pre-
cautions when tearing down or renovating buildings.
From the Departments of Infection Controla and Design and Construc-
tion,b The University Hospital, Cincinnati, Ohio; and the Department of
Internal Medicine,c Division of Infectious Diseases, University of Cincin-
nati College of Medicine, Cincinnati, Ohio.
Address correspondence to Francine Kidd, RN, BSN, CIC, 234 Good-
man, ML 0701, Cincinnati, Ohio 45245.
0196-6553/$32.00
Copyright ª 2007 by the Association for Professionals in Infection
Control and Epidemiology, Inc.
doi:10.1016/j.ajic.2006.07.011
In 1994, University Hospital had a cluster of Asper-
gillus infections in heart transplant patients. Construc-
tion restriction policies were initiated in response, and,
at this time, Infection Control added Aspergillus surveil-
lance to its targeted program. All new positive Aspergil-
lus isolates from the lower respiratory tract, wounds,
or sterile sites are investigated.
METHODS
Setting
The University Hospital (TUH) is the largest tertiary-
care hospital in Cincinnati, Ohio and its surrounding
metropolitan area. As part of the Health Alliance of
Greater Cincinnati, it has a level 1 trauma center; 7 in-
tensive care units, including a level 3 perinatal research
center and neonatal intensive care unit, and an adult
burn unit; and comprehensive outpatient services
with 450,000 visits per year. The University Hospital
admits more than 26,000 patients per year, has
85,000 emergency room visits, and an average daily

347
348 Vol. 35 No. 5
Fig 1. Key features of University Hospital Model
Program.
census of close to 400. It is the region’s major solid
organ transplant center.7 Parts of the original hospital
were built in 1910, 1927, and 1969. The existing hospi-
tal is 1,859,677 gross square feet, excluding the loading
dock and garage. At any one time, there are 4 to 6 major
renovation projects in operation.
INTERVENTIONS
In January 2000, the hospital began a 5-year expan-
sion project to build a 9-story employee garage, a
new postanesthesia care unit, a new cardiothoracic
intensive care unit, and to expand existing operating
room (OR) space to include 8 new ORs. To start, 5 circa
1910 mostly unused buildings had to be torn down. The
safe demolition of the old buildings was the first phase
of the project. During demolition, spores in old build-
ings and in the ground are stirred up and can infiltrate
into patient care areas.2-4 Because of the size and scope
Kidd, Buttner, and Kressel
of this 5-year project, the proactive infection control
education program for contractors was expanded. One
of the Infection Control Practitioners (ICPs) had at-
tended a University of Minnesota Health Care Facility
Construction Management Indoor Air Quality Work-
shop. The hospital project manager also was knowl-
edgeable about the important interventions needed to
protect our immunosuppressed patients. Many mem-
bers of our University Hospital’s Design and Construc-
tion Department are engineers and architects and
have attended classes on construction and infection
control.
Patients could not be relocated away from the area
of greatest activity, so all windows adjacent to the
demolition site were sealed with plastic. Prevailing
wind direction was monitored and extra prefilters
were added to all air intakes. Any dust generated during
demolition was wetted down. Air curtains were added
to doorways directly facing the construction. Immuno-
suppressed patients were notified to wear N95 protec-
tion when entering the hospital.8
Although the infection control requirements for per-
forming construction work are described properly in
all TUH construction specifications, the ground-level
workers on the site had little knowledge of the require-
ments, which often resulted in lack of adherence to
the policy. Typically, the project general contractor
did have a cursory understanding of the requirements,
but little information was passed on to those who actu-
ally were doing the job. In addition, to effectively im-
plement good quality patient protection, the workers
needed to understand the reasons for, and the infection
control qualities of, a well-managed hospital job site.
During the latter part of 1998, the infection control
and design and construction departments created an
audiovisual presentation to train our construction con-
tractors. With some additions, the same presentation
currently is being used. Contractors are much more
compliant with our infection control specifications if
they understand why we insist on them. An
explanation about Aspergillus and its transmission, and
the susceptibility of our immunosuppressed popula-
tion was added. The lesson plan is organized into sec-
tions that include precautions to be taken before,
during, and after the construction work is executed.
Topics discussed primarily address the containment
of construction dust. Training closely examines
methods of work inside and outside the construction
area, including establishing negative airflow and the
use of high-efficiency particulate air (HEPA) filtration,
tacky walk-off mats, ceiling access, and barriers.4
All of our construction personnel are required to
receive yearly infection control training. This includes
everyone from project managers to helpers. The class
takes about 30 minutes, and the project manager
 Kidd, Buttner, and Kressel
conducts it on a monthly basis. An ICP attends each
class to answer any questions.
Further, all construction staff must wear a hospital
identification badge per enforced hospital policy. After
their education, a sticker is applied on the badge indi-
cating the date that infection control training was
received. Any workers who have not had training can
be identified with a glance at their badge. It also elimi-
nates excuses and blame should a worker be found not
following precautions.
Education and policy compliance with positive
outcomes requires good quality assurance. The ICPs
make rounds on all projects at least weekly, and large
projects are visited daily. For the large project, weekly
rounds were established with an infection control
team.9 It includes the general contractor, project man-
ager, ICP practitioner, and OR nurse planner; others are
invited as needed. At one point, the construction site
was next to the heart transplant OR. Contractors had
to walk through the OR core to get to the project. The
team cooperatively established special procedures to
make the work possible while still protecting the pa-
tients. We built anterooms for contractors to change
between clean and dirty sites. They were required to
wear hair and shoe covers and bunny suits over their
clothing as they walked through the OR areas. Airflow
gauges monitor all of our negative airflow. OR staff
were taught how to read the gauges and what to do if
airflow was found to be positive. Contractors wet-mop-
ped floors several times during the workday to prevent
tracking. Construction workers did projects during off
hours if possible.
Before construction could commence, the ICP had
to inspect and approve the barrier—tagging it with a
specially made sticker—and had the authority to stop
the project if a breach in practice was found.
As our team met weekly, we continued to explore
better options and make adjustments to our interven-
tions. Footprints were still seen down the long hallways
toward the OR. A simple rule was initiated that elimi-
nated the problem; contractors were required to wear
OR booties over their shoes as they left the site. We
dedicated one elevator for construction use to separate
workers from OR staff and patients. When a large area
was demolished for renovation, we added more HEPA
filtration and fans to produce strong negative airflow
into the site.4 All work ceased until the airflow could
be corrected.
RESULTS
During the first 4 years of demolition and renova-
tion, TUH had no nosocomial Aspergillus infections.
Similar Aspergillus infection risks are present in the
context of large-scale construction projects external to,
June 2007 349
but near, the hospital.1,10 Similar protection methods
as described above were used when another large hos-
pital across the street demolished an old, large build-
ing. The demolition was near our OR air intakes.
In the fifth year of construction, 2 patients who had
possible hospital-infection were identified. An indus-
trial hygienist was brought in to evaluate our interven-
tions and make recommendations. Nothing of concern
was found. When the old buildings were first demol-
ished, particulate sampling was performed in high-
risk areas to measure our interventions. The sampling
was repeated when the first patient was identified.
Levels had not changed.
Both possible nosocomial Aspergillus infections oc-
curred after a building that was connected to the hospi-
tal, which shared air space with the hospital, began a
large renovation project without using infection con-
trol prevention. Some of our physicians had offices
in the building and walked back and forth between
the two. One of the cases was in a patient who never
came near any of our construction, but whose physi-
cian had an office in the adjoining building. We suspect
that these two Aspergillus infections during the fifth
year of our project were related to the neighboring con-
struction and renovation. Once again, our team collab-
orated with the other building’s contractors to make
changes. Our infection control training was used to
educate their contractors.
DISCUSSION/CONCLUSIONS
Efforts of today’s hospitals to meet increasing de-
mands, remain financially viable, and update aging in-
frastructure create renovation.5 Medical advancements
have led to more immunosuppressed patients, such as
transplant recipients, in hospitals. The combination
of these two factors has led to the increasing role of
infection control in construction/renovation projects.
Many hospital outbreaks have been documented;
most of those outbreaks were related to air contamina-
tion as the result of construction and renovation
projects.2,4,7,8,11,12
Although we had excellent compliance with our pro-
gram to reduce construction-related risk to patients, we
did have two cases of Aspergillus infection at the end
of the intervention period. We believe that this was sec-
ondary to external factors beyond our control, in this
case construction in an adjacent, nonhospital building.
This demonstrates that hospitals must be aware not
only of what is happening inside their own facilities
but also what is happening outside, although their abil-
ity to intervene may be limited.
One of the most challenging tasks of the ‘‘contem-
porary’’ ICP is establishing collegiality with contrac-
tors, architects, and maintenance and engineering
350 Vol. 35 No. 5
personnel. The ICP now must be knowledgeable in
matters of heating and air-conditioning, types of air
filters, wallboards, or plumbing. Many possess hard
hats and are not shy to use them!
In today’s health care atmosphere, multiple regula-
tory bodies have become heavily involved in regulating
projects to protect patients. Contractors have begun to
factor in extra infection control interventions when
they make their bids. The Centers for Disease Control
and Prevention issued the 230-page Guidelines for Envi-
ronmental Infection Control in Health-Care Facilities
in 2003. These guidelines make recommendations for
construction, renovation, remediation, repair, and de-
molition.13 The American Institute of Architects Acad-
emy of Architecture for Health (AIA) also publishes
guidelines for design and construction every 3 to 6
years.14 Shortly after the ‘‘turn of the century,’’ AIA
and the Joint Commission on Accreditation of Health-
care Facilities started to require an Infection Control
Risk Assessment for all construction and renovation
projects.9,11,13-17 At TUH, the assessment was initiated
almost immediately after the first guideline was issued.
The need for interventions was already being assessed,
but it often was vexing to determine how to document
our assessments. The risk assessment provided us with
a convenient means. Infection Control and Design and
Construction have a joint quality improvement project
that monitors and documents contractor compliance
with infection control practice.
The important piece of this model (Fig 1) is the trust
and good working relationships with all involved. As
the physical addition is constructed, so too must the ca-
maraderie be built. As a medical professional, the ICP is
entering the world of construction. The ICP must learn
how to become a member of the construction society
and give feedback, advice, and guidance without seem-
ing critical or demanding. At TUH, this did not happen
overnight. Each individual brings his/her special talent
to the job and each must be respected and acknowl-
edged for that contribution.
Through the years of major construction, the con-
struction workers jumped on the bandwagon. Our
own maintenance personnel were trained and they,
too, became infection control advocates. Today, it is
not unusual for a maintenance worker to call infection
control for advice when working on a repair project.
Other contractors keep infection control apprised of
smaller projects around the hospital. Design & Con-
struction automatically includes technique sink place-
ments, alcohol hand rub dispensers, and protective
equipment cabinets into specifications without infec-
tion control needing to advise.
Kidd, Buttner, and Kressel
The TUH Infection Control has achieved a collegiality
with all physical environmental associates to produce
an effective, comprehensive infection prevention atmo-
sphere during construction and renovation.
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