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10-525-00616 1 15 1 14 1 13 1 12 El South Miami Hospital L A Part of Baptist Health Systems Construction Infection Control Risk Assessment (ICRA) Matrix of Precautions Project Name and Number: Heart Center Sliding Glass Doors Location: 2 Floor North Tower AHCA Log Number: Project Manager: Luigi Ramudo K Architect: Linea 5 Engineer: Expert Consulting Services Contractor: Date Prepared: 4 -7 -10 NOTE` The ICRA Matrix shall be completed during preconstruction and approved by SMH Facilities, Safety, and Infection Control. Contractor shall sign the ICRA Agreement as part of the construction contract documents. Prescribed precautions must be in place prior to work start and must be maintained throughout the duration of the project. Step One: Using the following table, identify the TYPE OF CONSTRUCTION PROJECT ACTIVITY (Type A -D). 1 0 9 19 X N 1#00 A This project has been identified as CONSTRUCTION PROJECT ACTIVITY TYPE C SMH ICRA -page f - revised January 2006 Project Name and Number: Heart Center Sliding Glass Doors Location: 2 Floor North Tower AHCA Log Number: Project Manager: Luigi Ramudo Date Prepared: 4-7 -10 ICRA Matrix of Precautions - Appendix A. REQUIRED INFEC77ON CONTROL PRECAUTIONS BY CLASS SMH ICRA -page 5 - revised January 2006 11 I 10 1 9 1 Project Name and Number: Heart Center Sliding Glass Doors Location: 2 Floor North Tower AHCA Log Number: Project Manager: Date Prepared: 4 -7 -10 Step Two: Using the following table, identify the INFECTION CONTROL RISK GROUP (Low to Highest) based on the location and type of service that will be affected. Circle the specific risk group below. Low During Construction,orRenovation Upon Cornplogon/Prlorto Occupancy. 1. Execute work by methods to minimize raising dust 1. Wet mop/wipe exposed surfaces with �► from construction operations Echocardiography disinfectant 2. Immediately replace a ceiling ble displaced for visual Endoscopy Labor & Delivery Cardiac Cath Lab inspection. imaging Services Laboratories 1. Provide active means to prevent airborne dust from 1. Wet mop and/or vacuum with HEPA filtered Intensive Care Units dispersing into atmosphere PT /OT vacuum before releasing work area 2. Remove or isolate HVAC system in areas where 2. Wipe work surfaces with disinfectant Medical i Surgical Units work is being performed 3. Remove isolation of HVAC system in areas 3. Maintain negative pressure in work site. Conduct and inspection where work is being performed iVR document daily monitoring dispersing into atmosphere before releasing work area _ 4. Seal unused doors and above ceiling penetrations in CLASS filtration. Conduct and document daily monitoring 3. Remove isolation of HVAC system in areas where work Radiation Oncology surrounding walls before cutting roof surrounding walls before cutting roof 5. Place track mat at entrance and exit of work area 5. Remove or isolate HVAC system in areas where work is 6. Cover transport receptacles or carts. Tape covering 6. Cover transport receptacles or carts. Tape covering U unless solid lid 1. Complete all crit cal barriers (i e sheetrockr plywood; 1. Do not remove barriers from work are until completed 1, Complete all critical barriers (i.e. sheetrock, plywood; 1. 00 not remove barriers from work are until IiI sealed connection to work sate with HEPA vacuum prior plastic,) to seal area'from non work area or to exit) before construction begins completed project is inspected by SMH 2. Seal holes, pipes, conduits, and punctures` appropriately implement control cube method (cart with plastic, 3. Remove or, Isolate HVAC system in area where work is Safety and Infection Control being done to prevent contamination of duct system covering and seated connection to work site with 2.1 Remove barrier materials carefully to HEPA air filtration. Exhaust air may not discharge to HEPA vacuum prior ,to exit) before construction ceiling. Conduct and document daily monitoring minimize spreading of dirt and debris 5. Cover transport receptacles or carts. Tape covering begins unless solid lid associated with construction 2. Seat holes, pipes, conduits, and punctures 3 Vacuum work area with HEPA filtered 1. Complete all critical barriers (Le, sheetrock,'plywood, appropdatety plastic) to seat area frorn nen -work area or implement vacuums 3. Remove or Isolate HVAC system in area where work 4. Wet mop area with disinfectant CLASS ! vacuuming prior to exit) before construction begins. is being done to prevent contamination of duct 5. Remove isolation of HVAC system in areas 3. Construct anteroom and require all personnel to pass system through this room so they can be vacuumed using a where work is being performed 4, Maintain negative pressure in work site of > D,Olwg 6. Final cleaning by SMH Environmental each time they leave the vork site. using HEPA air filtration. Exhaust air may not 4. Remove or Isolate HVAC system in area where work is Services prior to occupancy being done to prevent contamination of duct system. discharge to ceiling, Conduct and document daily 5. Maintain negative pressure in work site of? 0 01wwg using _ monitoring ceiling. Conduct and document daily monitoring. 5. Cover transport receptacles or carts. Tape covering covers_ shoe covers must be changed each time the worker exits the work area unless solid lid before transport 7. Contain construction waste before transport in tightly �; 6. Contain construction waste in; tightly , Cofer transport receptacles or carts Tape covering unless solid lid, covered receptacles Parties agree to implement required precautions, notify the ICRA Team of necessary changes and institute corrective action immediately should violation of precautions be found. Contractor agrees to disseminate this information to subcontractors and assume responsibility 1, Complete all critical barriers (i.e. sheetrock, plywood, 1. Do not remove barriers from work are until Project Manager plastic) to seal area from non -work area or Facilities Manager completed project is inspected by SMH Infection Control Practitioner implementoontrol cube method (Cartwith plastic Safety officer Safety and infection Control covering and sealed connection to work site with 2. Remove barrier material carefully to HEPA vacuum for vacuuming prior to exit) before minimize spreading of dirt and debris construction begins: associated with construction. 2. Seal holes, pipes, oondults, and punctures 3_ Vacuum vrork area with HEPA filtered appropriately. vacuums. 3. Construct anteroom and require all personnel to pass 4, Wet mop area with disinfectant, through this room so they can be vacuumed using a 5 Remove isolation of HVAC system in areas HEPA vacuum cleaner before leaving work site or where work is being performed. require workers to wear cloth' or paper coveralls that 6. Final cleaning by SMH Environmental are removed each time they leave the work site. Services prior to occupancy 4. Remove or isolate HVAC system in area where work is being done to prevent contamination of duct system. 5. Maintain negative pressure in work site of > 0.01wg using HEPA air filtration. Exhaust air may not discharge to ceiling. Conduct and document daily monitoring. 6. All personnel entering work site are required to wear shoe covers. Shoe covers must be changed each time the worker exits the work area. 7. Contain construction_ waste before transport in tightly covered containers. 8. Cover transport receptacles or carts. Tape covering ` unless solid lid. SMH ICRA -page 5 - revised January 2006 11 I 10 1 9 1 Project Name and Number: Heart Center Sliding Glass Doors Location: 2 Floor North Tower AHCA Log Number: Project Manager: Date Prepared: 4 -7 -10 Step Two: Using the following table, identify the INFECTION CONTROL RISK GROUP (Low to Highest) based on the location and type of service that will be affected. Circle the specific risk group below. Low Medium High -Highest Office Cardiology CCU Immuno- compromised Pts Below Echocardiography Emergency Room Burn Unit N Lateral Endoscopy Labor & Delivery Cardiac Cath Lab E Lateral imaging Services Laboratories Central Sterile Supply, W Lateral Nuclear Medicine Newborn Nursery Intensive Care Units S Lateral PT /OT Outpatient Surgery Isolation Rooms REQUIRED PRECAUTIONS Respiratory Therapy Pediatrics Medical i Surgical Units 1. Wet mop/wipe exposed surfaces with disinfectant Cardiac Rehab Pharmacy NiCU inspection PACU iVR 1. Wet mop and/or vacuum with HEPA filtered vacuum dispersing into atmosphere before releasing work area Oncology 2. Wipe work surfaceswith disinfectant CLASS filtration. Conduct and document daily monitoring 3. Remove isolation of HVAC system in areas where work Radiation Oncology is being performed surrounding walls before cutting roof Operating Rooms/ 5. Remove or isolate HVAC system in areas where work is C- section Rooms This project has been identified as iNFEC77ON CONTROL RISK GROUP Step Three: Using the matrix below, match the CONSTRUCTION PROJECT ACTIVITY TYPE with the INFECTION CONTROL RISK GROUP to determine the CLASS OF PRECAUTIONS required. This project has been determined to require CLASS PRECAUTIONS. Note: SMH infection Control approval will be required when Class 11, /it, or IV Precautions are indicated. The required Precautions by Class are in the Appendix to this Matrix and included in the required ICRA Agreement (see Step Sixteen). Step Four: Identify the AREAS SURROUNDING THE PROJECT, assessing the potential infection control impact using the INFECTION CONTROL RISK GROUP designations from Step Two. What additional precautions should be considered based on this assessment? B. CONTRACTOR CONSTRUCTION ICRA AGREEMENT Project Name: Heart Center Sliding Glass Adjacent Service Area Doors Risk Group. Above Labor and Delivery Project Manager: Luigi Ramudo High Below Imaging Superintendent: Medium N Lateral Coridor ( } A Inspection, non - invasive activity ( } Low E Lateral NiA levels Low W Lateral ICU dust, requires greater 1 work shift Highest S Lateral CVCU requiring consecutive work shifts Highest What additional precautions should be considered based on this assessment? B. CONTRACTOR CONSTRUCTION ICRA AGREEMENT Project Name: Heart Center Sliding Glass Project Number., Doors Location of Work: 2 Floor North ToNver, , Start Date: Project Manager: Luigi Ramudo Estimated Duration: General Contractor: Office Phone: Superintendent: Cell Phone /Pager: TYPE OF CONSTRUCTION ACTMTY INFECTION CONTROL RISK GROUP ( } A Inspection, non - invasive activity ( } LOW ( } B Small scale short duration, moderate to high ( } MEDIUM levels ( } G Activity generates moderate to high levels of ( } HIGH dust, requires greater 1 work shift (X) D Major duration and construction activities ( X } HIGHEST requiring consecutive work shifts REQUIRED PRECAUTIONS During Construction Upon Completion 1. Execute work by methods to minimize raising dust from 1. Wet mop/wipe exposed surfaces with disinfectant CLASS construction operations I 2. Immediately replace a ceiling tile displaced for visual inspection 1. Provide active mans to prevent airborne dust from 1. Wet mop and/or vacuum with HEPA filtered vacuum dispersing into atmosphere before releasing work area 2. Maintain negative pressure of? 0.01wg using HEPA air 2. Wipe work surfaceswith disinfectant CLASS filtration. Conduct and document daily monitoring 3. Remove isolation of HVAC system in areas where work 11 3. Seal unused doors and above ceiling penetrations in is being performed surrounding walls before cutting roof 4. Place track mat at entrance and exit of work area. 5. Remove or isolate HVAC system in areas where work is being performed 6. Cover transport receptacles or carts. Tape covering unless solid lid 1. Complete all crit cal barriers (i e sheetrockr plywood; 1. Do not remove barriers from work are until completed plastic.) to seal area from non -work area or implement project is inspected by SMH Safety and Infection Control CLASS control cube method (cart With plastic covering and 2.' Remove barrier materials carefully to minimize IiI sealed connection to work sate with HEPA vacuum prior spreading of dirt and debris associated with construction to exit) before construction begins 3.' Vacuum' work area with HEPA filtered vacuums 2. Seal holes, pipes, conduits, and punctures` appropriately 4, Wet mop area with disinfectant 3. Remove or, Isolate HVAC system in area where work is 5 Remove isolation of HVAC system in areas wtiere work being done to prevent contamination of duct system is being performed 4. Maintain negative pressure in work site of >0.01wg using 6. Final cleaning by; SMH Environmental Services prior to HEPA air filtration. Exhaust air may not discharge to occupancy ceiling. Conduct and document daily monitoring 5. Cover transport receptacles or carts. Tape covering unless solid lid 6. Contain construction waste before transport in tightly covered receptacles 1. Complete all critical barriers (Le, sheetrock,'plywood, 1. Do not remove barriers from work are .until completed plastic) to seat area frorn nen -work area or implement project is inspected by SMH Safety and Infection Control control cube method (Cart with plastic covering and 2. Remove barrier material carefully to minimize spreadimg sealed connection to work site with HEPA vacuum for of dirt and debris associated with construction. CLASS ! vacuuming prior to exit) before construction begins. 3, Vacuum work area with HEPA filtered vacuums. N 2. Seal holes, pipes, conduits, and punctures appropriately. 4. Wet mop area with disinfectant. 3. Construct anteroom and require all personnel to pass 5. Remove isolation of HVAC system in areas where work through this room so they can be vacuumed using a is being performed. HEPAvacuum cleaner before leaving work site or require 6, Final cleaning by SNIH Environmental Services prior to workers to wear cloth or paper coveralls that are removed occupancy each time they leave the vork site. 4. Remove or Isolate HVAC system in area where work is being done to prevent contamination of duct system. 5. Maintain negative pressure in work site of? 0 01wwg using HEPA air filtration. Exhaust air may not discharge to ceiling. Conduct and document daily monitoring. 6. All personnel entering vxuk site are required to wear shoe covers_ shoe covers must be changed each time the worker exits the work area 7. Contain construction waste before transport in tightly coveted containers. Cofer transport receptacles or carts Tape covering unless solid lid, Parties agree to implement required precautions, notify the ICRA Team of necessary changes and institute corrective action immediately should violation of precautions be found. Contractor agrees to disseminate this information to subcontractors and assume responsibility for their compliance. SIGN WITH BLUE iNK ONLY Contractor Date Project Manager Date Facilities Manager Date Infection Control Practitioner Date Safety officer Date S 1 7 1 6 1 5 Project Name and Number: Heart Center Sliding Glass Doors Location: 2 Floor North Tower AHCA Log Number: Project Manager: Luigi Ramudo Date Prepared: 4 -7 -10 Step Five: identify SPECIFIC SiTE OF ACTIVITIES (e.g. patient rooms, medication rooms, etc.): 2 North Tower; Invasive Heart Center Step Six: Identify ISSUES RELATED TO VENTILATION, PLUMBING, AND ELECTRICAL in terms of the occurrence of probable outages: No plumbing work; electrical and duct work. Step Seven: Identify CONTAINMENT MEASURES using the prior assessments: What type of bafflers will be required? Plastic Containment Will HEPA filtration be required? Yes. Note: Renovation/construction shall be isolated from the occupied areas during construction and shall be negative (> 0.01 wg) with respect to surrounding areas. Step Eight: Consider potential RISK OF WATER DAMAGE. None Is there a risk due to compromising structural barriers (e.g. roof, exterior walls, etc)? No k If so, please explain nfa Step Nine: WORK HOURS - Can or will the work be done during non - patient care hours? yes. After 5 pm and on week ends. Step Ten: Do design plans allow for an adequate number of ISOLATION /NEGATIVE AIR FLOW ROOMS? NiA Step Eleven: Do design plans allow for the required number and type of HAND WASHING SINKS? nla Step Twelve: Does the INFECTION CONTROL STAFF AGREE with the minimum number of sinks for this project? (Note: design professional to verify against AIA guidelines for typesiareas) nla Adapted with permission V Kennedy, Barnard, developed at St. Luke's Episccpal Hospital, Houston, TX ICRA Permit SMH ICRA -page 6 - revised January 2006 0 IN N e Project Name and Number: Heart Center Sliding Glass Doors Location: 2 Floor North Tower AHCA Log Number: Project Manager: Luigi Ramudo Date Prepared: 4 -7 -10 Step Thirteen: Does the infection control staff agree with the plans relative to CLEAN AND SOILED UTILITY ROOMS? n/a Step Fourteen: Discuss the following CONTAINMENT ISSUES with the project team (comment as to how these will be addressed) Traffic flow - Will be affected. For emergency purposes the entrance to proceedure room B and E will be through the North entrance. Housekeeping - Work areas are to be cleaned and sanatized after each work shift and plastic containment is to be removed. Debris Removal - In covered carts and plastic bags. Step Fifteen: Obtain required APPROVAL SIGNATURES of the ICRA team: Sign with Blue ink Only Project Manager Date Architect Date Facilities Manager Date Infection Control Practitioner Date Safety Officer Date Step Sixteen: Implement through the CONTRACTOR CONSTRUCTION ICRA AGREEMENT (see Appendix). Steps 1 -3 Adapted with permission V Kennedy, B Barnard, St Luke Episcopal Hospital, Houston TX, C Fine CA Steps 4 -14 Adapted with permission from Fairview University Medical Center, Minneapolis MN Forms modified and provided courtesy of Judene Bartley, ECSI Inc. Beverly Hills, MN SMH ICRA - page 4 - revised January 2006 a oil nµw .�.I33UMD OR BID AND CONSTRUCTION DATE: 061/10110 CLIENT CODE/FILE NUMBER: 231100154 PROJECT ID- SUBMISSION NUMBER: 156 -001 ROBERT BROWN" r " i . 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