Assessing compliance of infection prevention mitigation strategies in hospital construction and renovation

Abstract

Hospital-associated fungal infections from construction and renovation activities can be mitigated using an infection control risk assessment (ICRA) and implementation of infection prevention measures. The effectiveness of these measures depends on proper installation and maintenance. Consistent infection prevention construction rounding with feedback is key to ongoing compliance.

Environmental disturbances in healthcare facilities that generate dust such as construction, renovations, remediation, repair, and demolition have been associated with a large number of fungal outbreaks. ^1–4 These outbreaks have most commonly involved patients with hematologic malignancies and other immunocompromising conditions. ^1,2 The causative pathogens of these outbreaks were usually Aspergillus spp, but Zygomycetes and other fungi have occasionally been reported. ¹ Importantly, the overall mortality of construction–renovation-associated fungal infection was ∼50%. ¹

Because of the frequency and high mortality of construction–renovation-associated fungal infections, proactive strategies for preventing such infections have been developed. ^1–3,5,6 An infection control risk assessment (ICRA) conducted before initiating repairs, demolition, construction, or renovation activities can identify potential exposures of susceptible patients to dust and moisture, and can determine the need for dust and moisture containment measures. ^5,6 This assessment centers on the type and extent of the construction or repairs in the work area but may also need to include adjacent patient-care areas, supply storage, and areas on levels above and below the proposed project. Developing an ICRA requires a multidisciplinary team approach to coordinate the various stages of construction activities (eg, project inception, project implementation, final walk-through, and completion). ⁵ Infection prevention staff along with staff from plant engineering facilities maintenance, environmental services, environmental health and safety, as well as stakeholders occupying areas adjacent to the construction–renovation space (eg, nursing, radiology, etc) must be represented in construction planning and design meetings. ⁵

Although the association of construction–renovation with fungal infections and developing and implementing an ICRA have been well described in the literature, the utility of routine “construction–renovation” rounds by infection prevention staff has not been previously assessed. Our facility has conducted infection prevention construction–renovation rounding for many years, but a formalized, multidisciplinary team rounding approach with a standardized checklist began in 2014. We performed this retrospective analysis of such rounds at our large academic hospital.

Methods

This study was conducted at a 951-bed academic medical center with 9 intensive care units, 4 intensive care step-down units, and 3 units dedicated exclusively to oncology care. The infection prevention department has 20 full-time employees. An ICRA is developed for all construction and renovation projects; an infection prevention staff member collaborates on the development and completion of the ICRA. Once construction starts, an infection preventionist (IP) leads fortnightly rounds in conjunction with life safety officers from plant engineering (PE) and environmental health and safety until the project is completed. Unannounced fortnightly rounding occurs on varying days and times to deter contractors from only effecting repairs when rounds are anticipated. The IP assesses up to 16 specific elements that reflect the implementation of appropriate infection prevention strategies. Construction projects (n = 140) were inspected multiple times (n = 1,085) since standardized rounding with a discrete rounding compliance tool was initiated in August 2014.

Here, we have summarized the overall compliance with each of these elements. In addition, the priority level of the finding is scored as low (eg, walk off mats not clean), medium (eg, debris cart covered during removal), high (eg, lack of negative pressure on unit housing immunocompromised patients) as well as whether the finding is a repeat event. The findings are shared in the form of real-time verbal feedback to the contractor’s site supervisor and are shared in writing with the plant engineering project manager and PE leadership. Any follow-up actions and dates are documented accordingly. Hospital-acquired fungal infection rates were reviewed from 2014 to June 2021. The data analysis was performed using Microsoft Excel software (Microsoft, Redmond WA).

Results

The compliance rates of the 16 infection prevention mitigation elements ranged from 77.4% to 99.9% (Table 1). The elements with the lowest compliance rates (<90%) were “Is the walk off mat clean and changed frequently?” at 77.4%, “Are barriers appropriate and properly sealed?” at 82.2%, and “Is the construction site under negative pressure?” at 86.1%. Hospital-acquired fungal infections did not statistically differ over time and ranged from 0.01 to 0.025 per 1,000 patient days.

Table 1. Compliance of Construction/Renovation Infection Prevention Measures from 2014 to 2021

Discussion

The 2 elements with the lowest compliance (ie, walk off mats and barriers sealed) are items that require ongoing inspection and daily maintenance. The other lowest performing element (ie, site under negative pressure) can require more premeditated planning and coordination to achieve. This particular element is deemed a high priority for repair if found deficient especially if the work is in an area housing immunocompromised patients. Regardless of repair priority if deficient, all of these 16 infection prevention measures are key elements to containing any potential fungal pathogens. Microbes can escape on shoes and wheels, through barrier gaps, and through the air as personnel enter and exit a site that is not under negative pressure (−0.01 mmHg). Over 7 years of construction rounding, we have observed marked improvements in compliance (Fig. 1), but this requires ongoing collaboration and education. Key strategies to proactively obtain compliance are PE staff and contractor education about the risk to patients, real-time feedback regarding deficiencies, management engagement, use of PE project coordinators to assist project managers with deficiency follow up, and construction specific policies that clearly address IP and safety expectations. Our facility has very low hospital-acquired fungal infections rates and no additional improvement was noted during the study period. The formalized rounding process was not started because of an outbreak but as a proactive, quality improvement–based infection prevention measure to protect our many immunocompromised patients.

Fig. 1. Mean compliance of infection prevention measures by year.

This study had several limitations. Repair priority is not well described and is determined subjectively by the rounding IP. There were 2 rounding IPs for construction during the 7 years of data collection (rounding IP no. 1 2014–2018; IP no. 2 2018–present). COVID-19 prevented rounding as a multidisciplinary team for of the majority of the year 2020. During that time, rounding was conducted individually, and findings were reported via e-mail.

In conclusion, the use of infection prevention measures to reduce the risk of hospital-acquired fungal infections has been well described; however, ongoing inspection and maintenance of these measures are required for optimal effectiveness. Given the association between fungal infections and construction–renovation in the hospital setting, a routine rounding and feedback tool, like we describe, is critical to ensuring appropriate and consistent implementation and operational effectiveness of the infection control risk assessment measures.