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July 24, 2014

You can protect patients with clean construction

  • High infection rates can hurt hospital revenues. Clean construction protocols play a role in reducing risks for patients.



    As the Affordable Care Act’s implementation drives the health care industry toward pay-for-performance, there is an increasing focus on improving patient satisfaction, reducing readmittance rates and eliminating the spread of health care-acquired infections (HAIs).

    Reimbursements from the Center for Medicare and Medicaid Services (CMS) are directly tied to a hospital’s performance in these categories, and the lowest performers will see their CMS payments reduced. With CMS reimbursements generally accounting for 60 percent of a typical hospital’s revenue, hospitals have a major incentive to improve performance.

    Many factors affect the spread of HAIs. Much of the existing literature and discussion centers on how clinical best practices can reduce the rate of HAIs, but the environment of care also plays a major role. This begins during construction; without proper clean construction protocols, patients can potentially be put at risk from dislodged mold and bacteria, volatile organic compounds, construction noise and vibration, or dust particulates.

    All players in the health care industry have a role to play in maintaining patient health and safety. The construction industry, which improves and maintains our nation’s health care facilities, has an especially significant responsibility to bear. However, the construction industry’s overriding focus on cost and schedule tends to overshadow the potential risks to clinical operations, which are difficult to quantify.

    Photos courtesy of McKinstry [enlarge]
    Patients in other areas of the hospital were unaffected by the construction of the new Seattle Children’s tower.

    Fortunately, the industry is changing. Environment of care specialists with health care facility-management experience are bringing a clinical operations perspective to construction.

    Developing and following clean construction protocols that protect patient spaces is a crucial goal the construction industry must have when working in the health care sector. The process of creating these protocols demands an integrated, collaborative approach that includes the design and construction team and hospital staff. By integrating ownership over patient outcomes between the designer, constructor and hospital, the health care industry reduces risk, saves money and, most importantly, protects patients.

    Covering the bases


    Planning is important to identifying and mitigating risk. To start, the team must create an infection-control risk assessment, which is a documented process that allows the team to anticipate potential risks of infection throughout the design and construction process.

    Developing the plan relies on a matrix between the invasiveness of the construction and the criticality of the space. Highly invasive construction (such as major renovations) in highly critical spaces (such as surgery rooms) requires extremely rigorous clean construction protocols, while less invasive construction projects (such as installing telephone cables) in less critical spaces (such as administrative offices) requires fewer protocols.

    Use the strictest clean-site precautions in critical areas such as surgery rooms.

    Haborview Medical Center faced hurdles replacing a surgery supply fan.

    Ducts must be thoroughly cleaned before they’re installed.

    In the end, getting buy-in from all stakeholders, including the hospital, architect, engineer, general contractor and subcontractors is the key step in ensuring the plan is comprehensive and will be followed.

    Separate spaces

    The construction space must be completely sealed from patient spaces. In ideal circumstances, the construction will happen in an unoccupied space.

    For example, when Children’s Hospital in Seattle added the eight-story Building Hope tower that connected to the existing facility through skybridges on each floor, the project remained physically separate from all patient spaces. No staff or materials ever passed through patient spaces.

    However, most projects occur in fully operational facilities. When Harborview Medical Center in Seattle replaced a surgery supply fan at the end of its life with a fan array system, the team encountered numerous infection-control hurdles in order to replace the fan while keeping the operating room suites operational. By using the above processes the team was able to uncover creative solutions to reduce the risk of HAIs.

    The team used air from a neighboring fan during off-hours work to maintain minimum airflow and proper pressure relationships in the operating rooms while the main supply fan was down for repairs. This avoided costly terminal cleaning while still maintaining proper infection-control standards.

    On another project at Harborview, the team was able to build a temporary pressurization chamber attached to the air-handling unit, which allowed for equipment to be moved in and out of the air-handling unit without shutting it down. This allowed for continued airflow, proper pressurization of patient spaces, and thus proper infection control.

    Clean materials

    Materials need to be properly cleaned before installation. For example, piping, ducts, and HVAC equipment should all be thoroughly cleaned (with an approved cleaning product if it’s for patient care and support areas) with the ends wrapped in plastic and the interiors wiped down.

    Clean sites

    All dust and debris can contain potential contaminants that may jeopardize the health of patients. Site staff should remove all dust daily using a vacuum with a HEPA filter.

    Personnel entering or exiting the construction site should be vacuumed or wear removable cloth or paper overalls that remain on site. Workers should also wear shoe covers that are changed every time they exit the work area, and a sticky mat should be placed anywhere a worker enters or leaves any project site adjacent to a health care environment.

    Quality assurance

    Finally, there must be a robust quality assurance and control plan in place to ensure that the established processes are maintained. It is the responsibility of both the hospital and the construction team to ensure that all agreed-upon processes are followed and standards are met.

    Much like the early stage ICRA or pre-construction risk assessment, there needs to be buy-in from both the hospital and the construction team so that all can hold each other accountable to the plan and the results.

    Other steps include the hourly review of both air and physical barriers, appropriate training, and final air-quality testing via an independent lab to ensure acceptability for patient care. It is important to work closely with the hospital infection prevention officer to ensure continual compliance with the hospital’s standards.

    Focus on outcomes

    Clean construction protocols aren’t simply a list of steps to take in keeping construction spaces clean. They are the catalyst to establishing an integrated, outcome-focused approach to construction in the health care industry.

    Integrated ownership over patient safety requires both the construction team and the health care staff to engage in a proactive discussion about reducing the spread of infections. The construction industry shares an important responsibility with their health care clients: to protect patients, visitors and staff from harm.

    Establishing and following clean construction protocols is a means to achieving this safe and a clean patient care environment.

    Dan Swanson, project director, has over 30 years of direct health care facilities experience. He manages the delivery of the majority of McKinstry’s health care projects. Tom Kelley, account executive, focuses on the health care industry for McKinstry’s energy services division.

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