Case Study: Risk Management in Health Care Construction Projects

• By Tom Petersen
• Jan 01, 2009

Health care workers are, like patients, subject to illness from a variety of airborne pathogens common to hospital settings. This risk increases during construction and renovation because these endeavors release dust and disease-inducing microbes into the surrounding environment. Because more than one in five workplace illnesses in private industry occur in a hospital setting, hospitals should consider the potential health impact of renovation and construction projects on their workforces.

This article will focus on how Frankford Hospitals, a health system based in Northeast Philadelphia, incorporates infection control procedures to limit the risk to its patients, employees, and vendors.

Worker Safety in Hospitals

Hospitals are under competitive pressure to continually upgrade and expand their facilities. Aging infrastructure, new technologies, and the increasing demand for more patient-friendly facilities generate a constant need for construction and repair.

Any one of these activities has the potential to release dust, bacteria, and mold-spores into the air. Some of the more common microbes that can be spread through construction activities include Stachybotyrs atra, Penicililum funiculosum, and Aspergillus fumigatus, a thermophillic fungus often found in construction dust.

The Centers for Disease Control and Prevention (CDC) publishes guidelines designed to manage the potential health impact of construction activities. These guidelines include resources for understanding modes of disease transmission, ventilation, environmental monitoring, and infection control. While the CDC recommendations were devised primarily with patient populations in mind, they are fully applicable as recommendations for workforce protection.

The following section discusses how Frankford Hospitals incorporated these recommendations, as well as many of its own disease-management solutions, into its infection control program.

Frankford Hospitals

Founded in 1903, Frankford Hospitals operates three hospitals and two outpatient centers in Northeast Philadelphia and Bucks County, Pa. With a mix of older infrastructure and newer facilities, it is not unusual for there to be several construction projects underway at one time. These range from simple repairs to complex renovations, such as building a new heart center or converting an operating room to accommodate new equipment.

Disturbing any building material--even something as simple as replacing a damaged ceiling tile--has the potential to release mold and dust. Patients, particularly those who are immuno-compromised, can become sick from exposure to these infectious agents in the ventilation system or in the drinking water supply. Sick patients can pass diseases onto workers, or workers can be sickened directly by the contaminants. Therefore, every project must be considered for its potential health impacts.

To manage this risk, Frankford has developed procedures for infection control during construction projects. These include: 1) regular meetings of a construction management team, 2) standardized risk assessments for building projects, 3) ongoing infection control training for staff and construction vendors, 4) air quality testing and environmental monitoring, and 5) guidelines for communicating with staff in a timely and accurate way.

Brief descriptions of these procedures follow:

1. Construction management team. The team meets weekly to review current construction activities and communicate with staff. The committee includes representatives from the laboratory, engineering, environmental services, administration, and risk management. Depending on the complexity of the project, meetings also may include architects, design engineers, contractors, and construction administrators.

2. Risk assessment. An Infection Control Risk Assessment (ICRA) is conducted for construction projects to determine the potential risk to patients and staff, as well as inform the appropriate regulatory agencies of ongoing activity. In Pennsylvania, these include the Department of Health and the Joint Commission (formerly Joint Commission on Accreditation of Healthcare Organizations, JCAHO).

The ICRA compares the complexity of building activities to their proximity to patient populations to determine what controls are needed. In addition, the ICRA process results in recommendations for the safety of construction personnel, such as wearing personal protective equipment, maintaining negative air pressure in the construction zone, or constructing an anteroom to prevent the spread of dust.

Frankford actually developed its own ICRA form, which was later adopted by the Pennsylvania State Plans Review Division.

3. Training. Hospital staff, contractors, and subcontractors are required to be familiar with infection control procedures. Contractors and subcontractors are required to pass a two-hour infection control course that Frankford offers. Some of the topics covered in the course include tuberculosis control, asbestos hazards, and bloodborne pathogen safety. Contractors that are not familiar with these procedures are not eligible to bid on projects.

4. Environmental monitoring. Environmental monitoring involves two types of activities: 1) daily physical monitoring of activities to make sure building activities and ICRA barriers conform to infection control and safety standards, and 2) air quality testing to assess whether the ICRA barriers are preventing construction dust from entering the active areas of the hospital. Air quality testing typically includes real-time particulate testing and also may include culturable fungal and bacteria samples.

Air quality testing, lab time, and generating reports adds costs, so facilities should review their budgets and objectives to make the best decisions about ICRA monitoring. Typically, these services are prioritized for situations when:

• There is evidence of water or water damage in an affected area.
• Mold growth is observed.
• Construction activity will generate dust.
• The project has the potential to affect the domestic water supply.
• The ventilation system may be affected by construction activity.

5. Communication. The construction management team meetings are used to keep the affected departments informed of ongoing construction activities. Information is then disseminated through a variety of means, including departmental meetings, memos, and e-mail.

There are also standard procedures for communication between the construction team and hospital administrators. For example, if a potential hazard is discovered, the director of facility design and construction is immediately involved. Additional steps may then be required to keep the staff informed.

The following section describes an instance where Frankford's procedures were implemented to address an infection control situation.

Putting the Plan into Action

Frankford was converting an operating room into a new central sterilization suite. Workers had removed an autoclave, exposing the wall behind it. During a weekly air quality test, we discovered large patches of mold on the wall.

We immediately informed Frankford's director of facility design and management, who ordered a hold on construction. Based on our recommendation, he also had the area quarantined off and ordered that staff whose work areas were near the construction be relocated until we could determine whether the mold was toxic. Next, we bulk samples to identify the type of mold and the extent of the contamination and determine whether there was any danger to hospital staff or construction employees. Frankford's management also informed the staff who worked in the area that mold had been found.

A number of the employees were upset and concerned their health would be affected. In this day of instant communications, the situation had the potential to escalate, so Frankford's management was eager to allay people's fears. Fortunately, the laboratory report came back negative for toxic mold, bacteria, or harmful particulates. These results were made known to the staff at a special meeting. The employees were allowed to read a copy of the report to validate our findings.

Using these results, we also made recommendations to Frankford regarding what remediation steps needed to be undertaken and what protective measures were required for the workers. We then conducted a visual inspection before giving the go-ahead for construction activities to resume.

These steps were repeated on several other occasions for other mold issues unrelated to construction. The investigations included visual inspection, mold and bacteria sampling and analysis, interviews with affected employees, and recommendations on remediation.

Conclusion

Hospitals will continue to build new and upgrade older facilities. Planners need to address the impact of these building projects on the health of workers and patients alike.

This article originally appeared in the January 2009 issue of Occupational Health & Safety.