NAME OF ORGANIZATION

Office file symbol SOP

No.
Disk File Name
Effective Date
Date Removed fom Sevice
INFE!TION !ONTRO" RIS# ASSESSMENTS $I!RA%
FOR DEMO"ITION& RENO'ATION& OR NE( !ONSTR)!TION PRO*E!TS
+. P,-ose. To co.tol micobial aibo.e co.tami.atio. i. occ,-ied -atie.t cae aeas d,i./ demolitio.&
e.ovatio.& a.d .e0 co.st,ctio. -o1ects.
2. A,t3oity.
a. *oi.t !ommissio. 4AS5SA!& latest editio..
b. Associatio. fo Pofessio.als i. I.fectio. !o.tol a.d E-idemiolo/y& I.c. $API!%.
c. Ameica. I.stit,te of Ac3itects $AIA%& G,ideli.es fo Desi/. a.d !o.st,ctio. of 4os-ital a.d 4ealt3
!ae Facilities& AIA& (as3i./to.& D.!. 266+.
7. Policy.
a. A m,ltidisci-li.ay team t3at i.cl,des I.fectio. !o.tol a.d Facilities Ma.a/eme.t 0ill co.d,ct a
-oactive I!RA d,i./ t3e desi/. a.d -la..i./ -3ase fo all demolitio.& e.ovatio.& a.d .e0 co.st,ctio.
-o1ects.
b. T3e team 0ill -ovide o./oi./ -la..i./ a.d mo.itoi./ d,i./ aea -e-aatio.8 t3o,/3o,t demolitio.&
e.ovatio.& o co.st,ctio. activities8 clea. ,- a.d -e-aatio. activities fo et,. to sevice8 a.d fi.al -o1ect
evie0 -3ases.
c. I!RAs 0ill foc,s o. -eve.tio.& b,t 0ill also addess mo.itoi./& testi./& a.d i.teve.tio. 03e. -oblems
ae ide.tified.
9. Res-o.sibilities.
a. 4os-ital5!li.ic !omma.de 0ill:
$+% A--oi.t a m,ltidisci-li.ay team t3at i.cl,des I.fectio. !o.tol a.d Facilities Ma.a/eme.t to e.s,e
ade;,ate ai ;,ality -eca,tio.s ae i. -lace a.d stictly e.foced 03e.eve co.st,ctio.& e.ovatio.& o
demolitio. activities ae -efomed i. occ,-ied aeas 0it3i. t3e Militay Teatme.t Facility.
$2% A--ove5disa--ove I.fectio. !o.tols ecomme.datio.s fo movi./ -atie.ts to a.ot3e aea of t3e
facility t3at is .ot affected by co.st,ctio..
+
b. Facilities Ma.a/e 0ill:
$+% Ide.tify at<isk co.st,ctio.& e.ovatio.& a.d demolitio. activities.
$2% !oodi.ate !lass II a.d 3i/3e co.st,ctio.& e.ovatio.& a.d demolitio. -o1ects 0it3 I.fectio.
!o.tol& Safety& Fie Mas3al& Sec,ity& 4o,sekee-i./& Eme/e.cy Ma.a/eme.t& Medical Mai.te.a.ce&
!omm,.icatio.s& de-atme.t -eso..el& a.d t3e co.tacti./ office=s e-ese.tative $!OR%5co.tacto.
$7% E.s,e co.tact doc,me.ts e;,ie co.tactos to im-leme.t I!RA e;,ieme.ts d,i./ co.st,ctio.
by i.cl,di./ t3e follo0i./& o simila la./,a/e i. all co.tacts: >INFE!TION !ONTRO" S4A"" APPRO'E
PRO*E!TS IN'O"'ING MANIP)"ATION OF !EI"ING TI"ES& PERFORMAN!E OF D)ST
GENERATING A!TI'ITIES& MANIP)"ATION OF 4EATING& 'ENTI"ATION& AND AIR
!ONDITIONING $4'A!% S?STEMS& P")M@ING& AND5OR OT4ER MAINTENAN!E REPAIRS PRIOR
TO T4E INITIATION OF T4E PRO*E!T.A
$9% I.itiate a. I!RA i. t3e desi/. a.d -la..i./ -3ase fo eac3 co.st,ctio. -o1ect.
$B% Ro,ti.ely mo.ito co.st,ctio. fo co.tacto com-lia.ce 0it3 t3e I!RA.
$C% I.s-ect co.st,ctio. aeas afte fi.al clea.i./ a.d a--ove o-e.i./5eo-e.i./ of t3e aea.
$D% 'eify t3at co.st,ctio. -eso..el eceive oie.tatio. a.d tai.i./ i. t3e i.fectio. -eve.tio. a.d
co.tol meas,es ide.tified o. t3e I!RA -io to stat of 0ok.
c. !3ief& I.fomatio. Ma.a/eme.t Divisio. 0ill:
$+% Notify t3e Facilities Ma.a/e of a.y -la..ed 0ok a.d obtai. a--oval -io to t3e stat of 0ok.
$2% Follo0 a--oved I!RAs to mi.imiEe t3e /e.eatio. of d,sts.
$7% E.s,e 0ok aeas ae -o-ely clea.ed ,- afte 0ok is com-leted.
d. I.fectio. !o.tol Office 0ill:
$+% Ide.tify 3i/3<isk -atie.t -o-,latio.s o aeas i. co.s,ltatio. 0it3 3os-ital staff.
$2% Detemi.e 03et3e co.st,ctio. -oses s,fficie.t i.ceased isk to e;,ie5ecomme.d t3at -atie.ts be
moved to a. aea of t3e facility t3at is .ot affected by co.st,ctio..
$7% Assist t3e Facilities Ma.a/e i. -e-ai./ co.tacto eF-ectatio.s fo i.fectio. co.tol -actices a.d
citeia fo eme/e.cy 0ok i.te,-tio.s.
$9% Ed,cate staff abo,t isks associated 0it3 -ote.tial eF-os,e to micobial co.tami.atio.& i.o/a.ic
-atic,lates& a.d volatile o/a.ic c3emicals es,lti./ fom co.st,ctio. activities.
$B% I.s-ect co.st,ctio. aeas afte fi.al clea.i./ a.d a--ove o-e.i./5eo-e.i./ of t3e aea.
$C% !o.d,ct o,ti.e s,veilla.ce to ide.tify .osocomial ill.ess& i.itiate e.vio.me.tal a.d
e-idemiolo/ical i.vesti/atio.s $i.cl,di./ etos-ective evie0s% to ide.tify a.d elimi.ate so,ces of i.fectio. if
2
moe t3a. o.e case is fo,.d& alet cli.icia.s cai./ fo 3i/3<isk -atie.ts& a.d establis3 a system fo -os-ective
s,veilla.ce fo additio.al cases.
e. !3ief& 4o,sekee-i./ 0ill:
$+% (ok 0it3 I.fectio. !o.tol to ide.tify aeas t3at .eed to be dam- mo--ed5clea.ed a.d clea. t3ese
aeas as sc3ed,led.
$2% T3oo,/3ly clea. .e0 a.d e.ovated aeas befoe admitti./ o eadmitti./ -atie.ts.
$7% !oodi.ate i.s-ectio. of fi.al clea.i./ 0it3 I.fectio. !o.tol a.d t3e Facilities Ma.a/e -io to
o-e.i./5eo-e.i./ t3e aea.
f. N,si./ De-atme.t 0ill:
$+% (ok 0it3 I.fectio. !o.tol to ide.tify 3i/3<isk -atie.ts5aeas.
$2% Follo0 -oced,es i. a--oved I!RAs d,i./ co.st,ctio..
/. I.d,stial 4y/ie.e 0ill:
$+% (ok 0it3 t3e Facilities Ma./e to develo- a.d cay o,t i.doo ai ;,ality a.d ve.tilatio.
assessme.ts as .eeded.
$2% (ok 0it3 I.fectio. !o.tol a.d t3e Facilities Ma./e d,i./ e.vio.me.tal i.vesti/atio.s.
$7% Recomme.d a--o-iate -eso.al -otective e;,i-me.t to be 0o. by co.st,ctio. -eso..el.
3. Safety Ma.a/e 0ill:
$+% E.s,e t3at t3e safety committee -eiodically evie0s t3e effective.ess of t3e I!RA d,i./
co.st,ctio..
$2% S3ae eleva.t safety a.d 3ealt3 i.fomatio. 0it3 t3e isk ma.a/e a.d -atie.t safety ma.a/e.
B. Poced,es.
a. !o.d,ct a.d doc,me.t I!RAs by com-leti./ ste-s + t3o,/3 C belo0.
7
Step 1. Use the following table to identify the type of construction.
Definitions of Construction Activities
Construction
Type
Description
A
I.s-ectio.s a.d .o.<i.vasive activities. I.cl,des& b,t is .ot limited to emoval of ceili./ tiles fo vis,al
i.s-ectio.& limited to + tile -e B6 s;,ae feet8 -ai.ti./ 0it3 mi.imal d,st -od,ctio.8 i.stalli./ 0all
covei./8 electical tim a.d mi.o -l,mbi./ 0ok8 a.d activities t3at do .ot /e.eate d,st o e;,ie c,tti./
of 0alls o access to ceili./s ot3e t3a. fo vis,al i.s-ectio.s.
B
Small<scale& s3ot<d,atio. activities t3at ceate mi.imal d,st. I.cl,des& b,t is .ot limited to i.stallatio. of
tele-3o.e a.d com-,te cabli./& access to c3ase s-aces& c,tti./ of 0alls o ceili./ 03ee d,st mi/atio. ca.
be co.tolled.
C
A.y 0ok t3at /e.eates a modeate to 3i/3<level amo,.t of d,st o e;,ies demolitio. o emoval of a.y
fiFed b,ildi./ com-o.e.ts o assemblies. I.cl,des& b,t is .ot limited to sa.di./ of 0all fo -ai.ti./ o 0all
covei./& emoval of floo covei./s& ceili./ tiles a.d case 0ok& .e0 0all co.st,ctio.& mi.o d,ct o
electical 0ok above ceili./s& ma1o cabli./ activities& a.d a.y activity t3at ca..ot be com-leted 0it3i. a
si./le 0ok s3ift.
D
Ma1o demolitio. a.d co.st,ctio. -o1ects. I.cl,des b,t is .ot limited to activities t3at e;,ie co.sec,tive
0ok s3ifts& e;,ie 3eavy demolitio. o emoval of a com-lete ceili./ system& a.d .e0 co.st,ctio..
Step 2. Use the following table to identify high-ris groups.
!nfection Control "is Assess#ent $Circle %ne&
'ow (ediu# (ediu#-)igh )igh
Office aeas
Ot3e:
All -atie.t cae aeas
$,.less stated i. medi,m to
3i/3 o 3i/3 isk aeas%
Ot3e:
Eme/e.cy Room
Radiolo/y5MRI
"abo G Delivey
N,seies
Pediatics
N,clea Medici.e
Admissio.5Disc3a/e ).its
P3ysiot3ea-y $ta.k aeas%
Di.i./ Facility
"aboatoies $s-ecime.s%
S-ecial Poced,es
Ot3e:
Ta.s-la.t Patie.ts
O-eati./ Rooms
PA!)
Steile Pocessi./ Aeas
All I!)s
!adiac !at3eiEatio.5
A./io/a-3y Aea
P,lmo.ay F,.ctio.
Dialysis ).its
E.dosco-ic Aeas
P3amacy MiFt,e Aeas
O.colo/y ).its
Ot3e:
Step *. Use the following table to define ris.
"is Assess#ent (atri+
Construction Activity
"is ,roup A B C D
Low I II II III5I'
Medium I II III I'
Medium-High I II III5I' I'
High III III5I' III5I' I'
9
Step -. Co#plete the !nfection Control Construction .er#it.
!nfection Control Construction .er#it
.ro/ect Description01u#ber2 .ro/ect Type2
HHHHMai.te.a.ce HHHHRe.ovatio.
HHHHDemolitio. HHHH!o.st,ctio.
HHHHOt3e:
3sti#ated Start Date2 3sti#ated Co#pletion Date2
4acility .ro/ect (anger2 .hone 1u#ber2
.ro/ect Contractor2 .hone 1u#ber2
!nfection Control %fficer2 .hone 1u#ber2
'ocation2 Area Supervisor0.hone 1u#ber2
Construction Type2
$!icle O.e%
A B C D
"is ,roup2
$!icle O.e%
Low Medium
Medium-High High
"is Assess#ent2
$!icle O.e%
I II III III/IV IV
.ro/ected Utility %utages !#pacting !nfection Control $(ar all that apply&
Electical Potable
(ate
4'A! Medical
'ac,,
m
Se0e Ot3e:
'ist All Construction 35uip#ent that #ay ,enerate 1oise6 7ibration6 and0or !nterference with (edical
35uip#ent $3lectro (agnetic !nterference&
B
.revention and Control (easures $(ar all that apply&
"is Assess#ent
I HH )se 0ok -actices t3at 0ill mi.imiEe /e.eatio. of d,st fom co.st,ctio. o-eatio.s.
HH Immediately e-lace a.y ceili./ tiles dis-laced fo vis,al i.s-ectio..
II HH Povide mea.s $e./.& fie<ated -lastic s3eeti./% to -eve.t aibo.e d,st fom
dis-esi./ i.to t3e atmos-3ee.
HH (ate mist 0ok s,faces to co.tol d,st 03ile c,tti./.
HH Seat ,.,sed doos 0it3 lo0 tack.
HH @lock off a.d seal ai ve.ts.
HH (i-e s,faces 0it3 disi.fecta.t.
HH !o.tai. co.st,ctio. 0aste befoe ta.s-ot i. ti/3tly coveed co.tai.es.
HH (et mo- a.d5o vac,,m 0it3 4EPA filteed vac,,m befoe leavi./ 0ok aea.
HH Place d,st mat at 0ok aea e.ta.ces a.d eFits.
HH Isolate 4'A! system i. 0ok aea.
III HH Isolate 4'A! system i. 0ok aea.
HH I.stall fie<ated baies o im-leme.t co.tol c,be met3od befoe co.st,ctio. be/i.s.
HH Mai.tai. .e/ative ai -ess,e 0it3i. 0ok aea& ,tiliEi./ 4EPA e;,i--ed ai filtatio.
,.its.
HH #ee- baies i. tact ,.til -o1ect is com-leted a.d aea is t3oo,/3ly clea.ed by
3o,sekee-i./.
HH 'ac,,m 0ok aea 0it3 4EPA<filteed vac,,ms fe;,e.tly.
HH (i-e s,faces 0it3 disi.fecta.t.
HH Remove baies caef,lly to mi.imiEe s-eadi./ dit a.d debis associated 0it3
co.st,ctio..
HH !o.tai. co.st,ctio. 0aste befoe ta.s-ot.
HH !ove 0aste ta.s-ot co.tai.es o cats& ta-e covei./s if lids o coves ae .ot ti/3t.
IV HH Isolate 4'A! system i. 0ok aea.
HH I.stall fie<ated baies o im-leme.t co.tol c,be met3od befoe co.st,ctio. be/i.s.
HH Mai.tai. .e/ative ai -ess,e 0it3i. 0ok aea& ,tiliEi./ 4EPA e;,i--ed ai filtatio.
,.its.
HH Seal 3oles& -i-es& co.d,its& a.d -,.ct,es a--o-iately.
HH !o.st,ct a.teoom a.d e;,ie all -eso..el to -ass t3o,/3 t3is oom so t3e. ca. be
vac,,med 0it3 4EPA vac,,m clea.e befoe leavi./ 0ok aea& o 0ea clot3 o
-a-e covealls t3at ae emoved eac3 time t3ey leave t3e 0ok aea.
HH Re;,ie all -eso..el e.tei./ 0ok aea to 0ea s3oe coves.
HH #ee- baies i. tact ,.til -o1ect is com-lete a.d t3oo,/3ly clea.ed by 3o,sekee-i./.
HH 'ac,,m 0ok 0it3 4EPA<filteed vac,,ms daily o moe fe;,e.tly as .eeded.
HH (et mo- ad1ace.t aeas 0it3 disi.fecta.t daily o moe fe;,e.tly as .eeded.
HH Remove baies i. a ma..e to mi.imiEe s-eadi./ dit a.d debis associated 0it3
co.st,ctio..
HH !o.tai. co.st,ctio. 0aste befoe ta.s-ot.
HH !ove 0aste ta.s-ot co.tai.es o cats& ta-e covei./s if lids o coves ae .ot ti/3t.
C
%ther "is-"eduction Strategies
HH #ee- -atie.t doos ad1ace.t to t3e co.st,ctio. aea closed.
HH Seal eFteio 0i.do0s to mi.imiEe i.filtatio. fom eFcavatio. debis.
HH Desi/.ate alte.ate o,tes i. t3e facility t3at deto, staff& -atie.ts& a.d visitos ao,.d t3e co.st,ctio. site.
HH Sc3ed,le ma1o co.st,ctio. -o1ects d,i./ 0i.te mo.t3s 03e. isk of f,./al i.fectio. is lo0est.
HH Desi/.ate a co.st,ctio.<o.ly elevato& e.ta.ce& a.d 0alk0ay fo co.st,ctio. ce0.
HH Remove co.st,ctio. debis t3o,/3 a 0i.do0 o. floos above t3e /o,.d level.
HH Relocate 3i/3<isk -atie.ts to a. aea emoved fom t3e co.st,ctio. site.
HH Post si/.a/e elated to .o.<a,t3oiEed e.ty i.to t3e 0ok aea.
HH Desi/.ate stoa/e aeas fo co.st,ctio. mateials.
HH Tai. a.d ed,cate 3ealt3cae staff& facility 0okes& co.st,ctio. 0okes $Mak all t3at a--ly%:
I.fectio. !o.tol EF-os,e !o.tol Pla.s& 4aEado,s !3emicals& "ife Safety& Accide.t Re-oti./&
Fist Aid& Peso.al Potective E;,i-me.t& Re-oti./ ,.eF-ected e.vio.me.tal eme/e.cies $e./.& lead
-ai.t& asbestos& etc.%
HH Ot3e:
D
Step 8. Co#plete daily #onitoring to ensure worers0contractors follow infection control guidelines and
policies.
!nfection Control Checlist
During Construction0"enovation
!nspector2 'ocation2 Date2 Ti#e2
9arriers Air )andling
!o.st,ctio. si/.s -osted All 0i.do0s be3i.d baie closed
Doos -o-ely closed a.d sealed Ne/ative ai -ess,e at baie e.ta.ce
4oles& -i-es& co.d,its& -,.ct,es& etc. sealed Potable ai flo0 ,.its ,sed to mai.tai. .e/ative
-ess,e ,..i./ D,st baies i.tact a.d sealed
Floo a.d 3oiEo.tal s,faces fee of d,st Trash and Debris
!eili./ tiles fee of moist,e No visible evide.ce of i.sects $flies%
Traffic Control Tas3 -laced i. a--o-iate co.tai.es
All doos a.d eFits fee of debis Ro,ti.e clea.i./ -efomed i. 0ok aea
Resticted to co.st,ctio. 0okes a.d esse.tial
staff
>StickyA d,st mats a--o-iately -laced5clea.
No evide.ce of d,st o,tside t3e co.st,ctio. aea
.ersonal .rotective 35uip#ent $..3& Debis emoved i. coveed co.tai.e daily
(okes 0eai./ a--o-iate PPE Re/,lated medical 0aste co.tai.es emoved fom
0ok aea befoe 0ok is stated
C%((31TS0ACT!%1S TA:312
I
Step ;. Co#plete final infection control inspection upon co#pletion of construction0renovation.
!nfection Control Checlist
4inal Upon Co#pletion of Construction0"enovation
!nspector2 'ocation2 Date2 Ti#e2
35uip#ent
Soa- dis-e.ses -o-ely i.stalled a.d filled To0el dis-e.ses -o-ely i.stalled a.d filled
Si.ks f,.ctio.al S3a-s co.tai.es -o-ely i.stalled
)ouseeeping
(aste a.d eFcess e;,i-me.t5s,--lies emoved S,faces a.d floos d,st fee
7entilation
A--o-iate -ess,e elatio.s3i-s veified Ai i.take5eF3a,st ve.ts fee of -otective
covei./s
C%((31TS0ACT!%1S TA:312
J
b. If a .osocomial i.fectio. occ,s d,i./ co.st,ctio.& i.te.sify s,veilla.ce to ide.tify additio.al cases&
seac3i./ bot3 -os-ectively a.d etos-ectively. If .o evide.ce of o./oi./ ta.smissio. is discoveed&
co.ti.,e 0it3 o,ti.e i.fectio. co.tol meas,es. I. t3e eve.t moe t3a. o.e case is fo,.d& co.d,ct
e.vio.me.tal a.d e-idemiolo/ical i.vesti/atio.s to ide.tify a.d elimi.ate t3e so,ce of i.fectio..
S,bmitted by Date
A--oved by Date
+6