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Hospital Renovation & Construction

What They Didn’t Tell You in IC 101

By Schraag

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.â€

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.â€

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.â€

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.â€

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.â€

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.â€

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.â€

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.â€

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.â€

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.â€

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.â€

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,â€

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.â€

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.â€

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.â€

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.â€

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.â€

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.â€

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.â€

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.â€

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.â€

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.

____________________________________

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_

(http://www.aia.org/aah) . Details and registration information will be posted

online

as it becomes available.

____________________________________

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.â€

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,â€

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

pati

ent 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.â€

“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.â€

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.â€

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.