Risks and Costs of Construction-Related

Infections: New Approach to Containment

Monitoring Protects Patients and Hospitals

Bryan F. Connors, M.S., C.I.H., Practice Director, Healthcare

Environmental Health & Engineering, Inc.

EH&E | 117 Fourth Avenue | Needham, MA 02494 | 800-825-5343

 Risks and Costs of Construction-related Infections: New Approach to Containment Monitoring Protects Patients and Hospitals

INTRODUCTION
Construction projects can present major threats to patient safety by impacting the continuous delivery of
care and increasing the risk for development of life-threatening healthcare-acquired infections (HAIs).
Maintaining effective isolation of the construction site is critical in preventing compromises in the clinical
environment while ensuring uninterrupted patient care and construction schedules. Current practice depends
upon periodic inspections and spot monitoring of environmental conditions to confirm isolation throughout
all stages of a project.

This white paper presents a solution for enhancing patient safety and asset protection by applying
commercially-available technology for continuous site surveillance on a 24/7 basis, enabling “Smart Alerts”
to be issued via email and text messages to the construction team, and utilizing web-based dashboards for
reporting and data visualization of real-time conditions. These systems safeguard patient safety and in doing
so, avoid costs associated with treatment of HAIs as well as interruptions in construction activities that can
lead to costly scheduling delays.

WHY MONITOR? THE RISKS AND COSTS OF CONSTRUCTION-

RELATED INFECTIONS
Every construction project, regardless of scale, can pose
potential risks to patients, staff and adjacent physical assets from
exposure to dust, vehicle and equipment exhaust, odors and
chemicals associated with construction activity. As a result,
construction and maintenance activities are seen as a major risk
by The Joint Commission. The mandated Pre-Construction Risk
Assessment (PCRA) and Infection Control Risk Assessment
(ICRA) processes are essential to provide thoughtful evaluation
of necessary controls prior to beginning each project. Furthermore, the Centers for Disease Control and
Prevention (CDC) has established an extremely low threshold for mold in hospitals.1 The risk of illness and
even death to vulnerable patients is of the utmost concern during times of construction.

Studies show that more than half of the HAIs related to Aspergillus (a common mold) are caused by
construction activities in hospitals.2 A recent study identified 31 cases of HAIs due to mold during a ten-
month construction period at a large medical center.3 A separate study determined that the attributable
mortality of Aspergillus-related pneumonia for a bone marrow transplant patient is estimated to be a
staggering 85% .4

These studies clearly illustrate that the risks are high and they are real. Infections due to construction
activities do happen and it can be deadly for the patients. Additionally, there are significant costs associated
with HAIs that must be borne by the hospital. The additional treatment cost for a single case of hospital-
acquired Aspergillosis is $60,000. 4 This significantly reduces hospital profits because they are rarely fully
reimbursed for the cost of treating HAIs. This does not include the cost of stopping construction activities,
disruption to hospital operations, negative publicity and damage to the hospital brand.

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 Risks and Costs of Construction-related Infections: New Approach to Containment Monitoring Protects Patients and Hospitals

>50% of HAIs related to Aspergillus (common mold) are caused by construction

Number of cases of HAIs due to mold during 10-month construction
31 period in a single hospital
Estimated attributable mortality of Aspergillus-related pneumonia for bone
85% marrow transplant patients
Cost of additional treatment for a single case of hospital-acquired
$60,000 Aspergillosis
Monthly cost of two automated, 24/7 monitoring stations (two parameters;
$7,500 pressure and dust, which serves as a surrogate for testing mold.)

LIMITATIONS OF CONVENTIONAL CONSTRUCTION MONITORING PROGRAMS

Containment and control measures are determined by the highly standardized PCRA and ICRA procedures.
Typical construction containment measures include sealing doors, isolation of ductwork, enclosing the
construction area, wetting the site periodically, special filtration, or providing ventilation equipment to
exhaust air from the construction site to the outside.

Construction projects are dynamic and conditions can change rapidly. Even the most effective containment
measures may not function as planned once construction commences. Regular environmental monitoring
verifies that the control measures are working properly, and that the surrounding areas and populations are
not adversely affected. Regular monitoring includes routine audits of construction areas, dust level
monitoring at key locations, and site tours using hand-held monitoring devices to determine how the
containment measures are performing. Visual inspections are helpful in verifying that the correct control
measures are being followed; however, they do not provide the hard data required for proof of containment
and verification that surrounding areas have not been negatively impacted. The hand-held or stationary dust
monitors that are primarily used require data analysis back at the office with subsequent delayed
communications to the construction team. In the event of an unrecognized containment breech, such
notification can lag an event by many hours to a day, requiring mitigation actions to be undertaken
retroactively. This response gap poses significant risk and can have disastrous consequences for patients,
staff and sensitive hospital assets (compounding pharmacy, operating room, bone marrow transplant units).
Most construction projects last for a period of weeks or months, and the amount of time that periodic hand-
held monitoring captures is only a tiny fraction (usually less than 1%) of the active construction project
time. It is this long delay in response and significant gap in protection that EH&E’s automated monitoring
system addresses.

WHEN IS AUTOMATED CONSTRUCTION MONITORING ESSENTIAL?

EH&E has developed construction monitoring risk management programs for numerous healthcare projects,
of all sizes and levels of complexity, throughout the U.S. Based on this extensive experience, we developed
guidelines for when automated construction air quality monitoring is critical to ensuring patient safety and
minimizing risk. The decision to conduct automated construction monitoring should be made as part of the
PCRA / ICRA assessment. EH&E’s matrix, presented below, is a useful guide when developing a sampling
strategy for any construction project. The sampling strategy may also need to take into account additional
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 Risks and Costs of Construction-related Infections: New Approach to Containment Monitoring Protects Patients and Hospitals

factors such as size and scope of the project, mechanical filtration in the areas being served, history of
adverse events (environmental fungal infections and floods within the facility), as well as professional
judgment and experience.

Matrix: EH&E Guidelines for Evaluating Construction Monitoring Effectiveness

ICRA Class

Project Duration I II III IV

1 – 7 days A A B N/A

2 – 8 weeks A B C C

2 months + N/A N/A C C

A No routine sampling recommended.

Conduct periodic airborne particle monitoring.
B Conduct continuous differential pressure monitoring.
Mold sampling only when indicated by adverse event.
Conduct continuous 24/7 remote particle and pressure monitoring.
C
Consider the need for periodic (e.g., monthly) viable fungi sampling for highest risk areas.

HOW AUTOMATED CONSTRUCTION MONITORING WORKS

EH&E’s automated construction air quality monitoring system involves four key components: the remote
monitors, the data interpretation algorithm, alerting system (email or text message), and web-based
dashboard. Together they eliminate a great amount of manual labor involved in collecting, processing, and
interpreting data for key decision-makers – the construction team and hospital stakeholders. More
importantly, the system delivers immediate, vital project information to the construction team and hospital
stakeholders when action is required to prevent exposure.

Appropriate locations are selected during the PCRA / ICRA review based on construction activities and
additional factors such as prevailing winds and proximity of sensitive assets and populations. Every
monitoring system is customized to meet the needs and goals of the particular construction project. The
system is designed to be deployed anywhere, whether in the most active of construction sites, or in the
midst of highly sensitive areas or populations. Monitoring equipment uploads data in real time to a secure
data platform where it is processed, and from which automated email or text message alerts are released.

The secret to a successful automated monitoring program is setting the data collection algorithms properly
for each sampling parameter. If alerts are constantly or falsely generated, it leads to alarm fatigue for both
the project team and stakeholders. EH&E’s industrial hygienists incorporate industry standard guidelines
and project-specific information to develop adequate margins of safety for the alert triggers. This means
alerts will only be triggered if there is a potential problem onsite. Unit calibration, performance issues, and

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 Risks and Costs of Construction-related Infections: New Approach to Containment Monitoring Protects Patients and Hospitals

ambient environmental conditions are also accounted for. This automated, pre-determined “Smart Alarm”
system delivers more efficient and effective responses for hospitals.

The fully customized web-based dashboard makes it easy for all stakeholders to get an overview of the
current status of the construction project. The dashboard presents a high-level summary of the project status
and allows users to drill down to individual measurements and other specific information. The dashboard
can incorporate results from the construction containment audits, and airborne dust and relative pressure
data as an indication of the adequacy of construction site isolation. Dashboards are a valuable tool to help
create transparency and establish confidence in construction performance and oversight.

AN EFFECTIVE, COST-EFFICIENT INFECTION PREVENTION AND RISK MANAGEMENT STRATEGY

The very low threshold for potentially deadly infections in the event of even a brief breach in construction
site isolation near sensitive hospital environments underscores the critical need for continuous, automated
monitoring to ensure the safety of patients and staff and to minimize hospital liability. Furthermore, the
recent shift of the cost of HAIs to the hospital has created a strong business case for infection prevention
strategies.

Automated construction air quality monitoring is a proven effective strategy for infection control and risk
management. It provides full-time protection for patients, staff and hospital assets. Additionally, it saves
hospitals money through the avoidance of disruptions to critical hospital operations and construction delays
that result from having to shutdown a construction project.

AUTOMATED CONSTRUCTION MONITORING: PROVEN SUCCESS

The benefits of automated construction air quality monitoring are clearly demonstrated in results from
many successful projects in various healthcare settings. Table 1 illustrates five separate hospital
construction projects that employed continuous automated monitoring. Over the course of 3,751 total
hours monitored, there were 104 Level 2 alerts (Level 2 alerts require intervention). The average time
from alert to resolution of the containment issue was under one hour. The rapid response meant that none
of the projects had to be shutdown – construction activities and hospital operations were able to continue
safely without interruption, and patient health was protected.

(Case study continued on next page)

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 Risks and Costs of Construction-related Infections: New Approach to Containment Monitoring Protects Patients and Hospitals

Table 1 Automated Construction Monitoring Projects Results - The average time from alert to resolution was under one
hour and there were no project shutdowns.
Total Construction Total Level Two Total Time Under Average Time to
Construction Total Project
Monitoring Time Alerts* During Level Two Alert Resolve a Level Two
Project Shutdowns
(hours) Construction (hours) Alert (hours)
Endoscopy Upgrade 1,832 36 22 0.6 0

Hospital Main Lobby 499 46 37 0.8 0

Fixed MRI Area 341 6 8 1.3 0

Exterior Demolition 390 10 9 0.9 0

Patient Care Area
689 0 0 NA 0
Renovation

For the five example construction projects, EH&E designed alert levels to be protective of health and
consistent with industry practice. EH&E recommended alert levels defined by two conditions; the absolute
concentration of the indicator air pollutant and an indicator of whether or not the absolute concentrations are
likely to be project-related. The project-related activities are monitored through site inspections,
communications with the project team, and the construction schedule. Figure 1 shows continuous particle
monitoring data collected on one day of construction during which there was a single event that triggered a
Level 2 alert. An alert was sent directly to the project manager, who initiated a response action within minutes.
The time from initial exceedance to levels returning to baseline was approximately two hours.

Response Action Completed

Project Team Contacted

Response Action Initiated

Level 2 Alert

Start of Construction Day

End of Construction Day

Level 2
Alert Level

Figure 1 During a single day of construction there was an event that triggered a Level 2 alert. With the automated
monitoring program in place, the team was able to respond immediately and resolve the issue within one hour.

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 Risks and Costs of Construction-related Infections: New Approach to Containment Monitoring Protects Patients and Hospitals

REFERENCES
1 Centers for Disease and Control Prevention’s Guidelines for Environmental Infection Control in
Healthcare Facilities (2003)
2 Punke, Heather “Hidden Risks of Hospital Construction Projects: HAIs” Becker’s Healthcare. 8 Jan.
2015. Web 21 May 2015.
3 Pokala, HR Leonard, D, Cox, J, Metcalf, P, McClay, J, Siegel, J Winick, N. Association of Hospital
Construction with the Development of Healthcare Associated Environmental Mold Infections (HAEMI)
in Pediatric Patients with Leukemia. Pediatric Blood Cancer. 2014 Feb; 61(2): 276-280.
4 Krueger, KP and Nelson, AC. Economic considerations in the treatment of invasive aspergillosis: a
review of voriconazole pharmacoeconomic studies. ClinicoEconomics and Outcomes Research. Aug.
2009; Vol. 2009:1

Bryan F. Connors, M.S., C.I.H. is a Senior Scientist / Practice Director, Healthcare at EH&E. He provides operational
guidance and technical support for the healthcare sector in support of Joint Commission Environment of Care and
Emergency Management compliance, infection control, industrial hygiene, and regulatory compliance with the U.S.
Occupational Safety and Health Administration (OSHA).

Bryan has extensive program management experience in Environment of Care programs in healthcare. He has performed
several infection investigations and developed facilities-related infection prevention programs for construction renovation risk,
Legionella, USP 797, and hospital physical assets in complex hospital environments.

Bryan can be reached at 1-800-825-5343 or at BConnors@eheinc.com

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