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Infection Control Risk Assessment (ICRA)
Matrix of Precautions for Construction
7'roject Name and Number: SMH NICU Operating Room
Location: 3 ird floor North Tower
Description • project: Demo existing area to build out operating room.
Note: The ICRA Matrix shall be completed duting preconstruction and approved by the Facilities Safety,
and Infection Control Officer. 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
Inspection and Non-Invasive Activities.
includes, but is not limited to:
Removal of ceiling tiles for visual inspection limited to I tile per 50 square feet
100
Painting (but not standing)
Wall covering, electrical trim work, minor plumbing, and activities which do not generate dust or
reauirecuttin • of walls • access to ceilings other than for visual inspection.
Small scale, short duration activities which create minimal dust.
Includes, but is not limited to:
0 Installation of telephone and computer cabling
9 Access
• chase spaces
* Cutting of walls or ceilino where dust miaration can be controlled
Work that generates moderate to high level of dust or requires demolition or removal of any fixed
building components or assemblies.
Includes, but is not limited to:
• 0 Sanding of walls for painting or wallcovering
0 Removal • floorcovering, wall covering, ceiling tiles and Casework
0 New wall construction
* Minor duct work or electrical work above ceilings
0 Major cabling activities
* Any acfivitv which cannot be comUleted within a sinqle work shift
Major demolition and constructlow projects.
I lu•6 but is not limited to
nc
Type Pa� Activities which require Consecutive work shifts.
em • on-6riemo
0 v6l,of a comp ete�ca I • g system
RequireSheav • I
New construction
This project has been identified as CONSTRUCTION PROJECT ACTIVITY TYPE ( D:
0
BHS 107 Agreement
Z
BHS 107 Agreement
Step Two:
Using the following table, identify the Patient Risk Groups that will be affected. If more than one risk group
will be affected, select the higher risk group:
Infection Control Approval_ �Y-D�ate:
2
mfection Control Agreement Risk Assessment (ICRA)
Matrix of Precautions - Appendix A
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Risk-
-- -- ----
-ftif-Risk,
is
Highe61Mk
• Office Areas
• Cardiology
• JEmergency Room
• uno-compromised
Class 1 1.
• Echocardiography
�_Labor & Delivery
Patients
Type A: Inspection, non-invasive activity.
• Endoscopy
• Laboratories (specimen)
• Cardiac Cath Lab.
2.
• Imaging Services
• Newborn Nursery
• Central Sterile Supply
Type C: Activity generates moderate to high levels of dust, requires
• Nuclear Medicine
• Outpatient Surgery
• All Intensive Care Units
Class 11 1.
• Physical Therapy
• Pediatrics
• Medical / Surgical Units
Type D: Major duration and construction activities requiring consecutive
• Occupational Therapy
• Pharmacy
• Negative Pressure Isolation
Z
• Respiratory Therapy
• Post Anesthesia Care Unit
Rooms
3.
• MRI
• Interventional, Radiology
4.
• Cardiac Rehabilitation
3.
• Oncology
5.
Remove or Isolate HVAC system In area where work is
• Operating rooms including C
J
being done to prevent contamination of the duct
4.
Section Rooms.
Infection Control Approval_ �Y-D�ate:
2
mfection Control Agreement Risk Assessment (ICRA)
Matrix of Precautions - Appendix A
1=67m 61111immewomine NVIEw-MUST21MME
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Step 4:
Identify the areas surrounding the project area, assessing potential impact using the INFECTION
CONTROL RISK GROUP designation from Step Two.
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Actions to be performed
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Actions to be performed
E Lateral
during Construction or Renovation
Superviso el.:
upon Completion/ Prior to Occupancy
Class 1 1.
Execute work by method to minimize raising dust from
1.
Wet mop/wipe exposed surfaces with appropriately
Type A: Inspection, non-invasive activity.
the construction operations.
Group 1: Low Risk
labeled and BHSF approved hospital disinfectant.
2.
Immediately replace any ceiling the displaced for visual
Group 2: Medium Risk
Type C: Activity generates moderate to high levels of dust, requires
inspection.
Group 3: Medium/High Risk
Class 11 1.
Provides active means to prevent air-borne dust from
1.
Wet mop/wipe exposed surfaces with appropriately
Type D: Major duration and construction activities requiring consecutive
dispersing into atmosphere.
Group 4• Highest Risk
I
labeled and BHSF approved label disinfectant,
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Water mist work surfaces to control dust while cutting.
2.
Contain construction waste before transport in tightly
3.
Seal unused doors with duct tape.
covered solid lid containers.
4.
Block off and seal air vents.
3.
Wet mop and/or vacuum with HEPA filtered vacuum
5.
Remove or Isolate HVAC system In area where work is
before leaving work area.
J
being done to prevent contamination of the duct
4.
Remove isolation of HVAC system in areas where work
system.
1. Provides active means to prevent air -home dust from dispersing Into
Is being performed.
6.
Place dust mat at entrance and exit of work area
approved label disinfectant.
7.
Wipe surfaces with disinfectant.
3. Seat unused doors with duct tape.
8.
Cover transport receptacles or carts. Tape covering
4. Block off and seal air vents.
3. Wet mop and/or vacuum with HEPA filtered vacuum before leaving
unless solid lid.
work area.
Class 111 1.
Remove and isolate HVAC system in area where work
1.
Do not remove barriers from work area until completed
performed.
is being done to prevent contamination of the duct
7. Wipe surfaces with disinfectant.
project is thoroughly inspected by Owners staff.
Cornm.No: 11087.00
system.
2.
Vacuum work with HEPA filtered vacuums.
Z
Complete all critical barriers i.e. sheet rock, plywood,
3.
Wet mop/wipe exposed surfaces with appropriately
thoroughly inspected by Owners staff.
plastic, to seal area from non work area or implement
2. Complete all critical barriers i.e. sheet rock, plywood, plastic, to seat
labeled and BHSF approved hospital disinfectant.
control cube method (cart with plastic covering and
4.
Contain construction waste in tightly covered containers
with plastic covering and sealed co work site with HEPA vacuum
sealed co work site with HEPA vacuum prior to exit)
before transporting.
4. Contain construction waste In tightly covered containers before
before construction begins.
5.
Cover transport receptacles or carts. Tape covering
3.
Maintain negative air pressure within work site utilizing
5. Cover transport receptacles or carts. Tape covering unless solid lid.
unless solid lid.
4. Contain construction waste in tightly covered containers before
HEPA equipped air filtration units.
6.
Remove isolation of HVAC system In areas where work
4.
Contain construction waste in tightly covered
5. Cover transport receptacles or carts. Tape covering unless solid lid.
is being performed.
containers before transporting.
7.
Remove barrier materials carefully to minimize
5.
Cover transport receptacles or carts. Tape covering
spreading of dirt and debris associated with
1. Do not remove barriers for work area until completed project is
unless solid lid.
contamination of duct system.
construction.
6.
Seal holes, pipes, conduits and punctures
8.
Final cleaning by Environmental Services prior to
area from non work area or Implement control cube method (cart
appropriately
occupana.
Class IV 1.
Isolate HVAC system in area where work is being
1.
Do not remove barriers for work area until completed
done to prevent contamination of duct system.
transporting.
project Is Inspectstaff. , by the Owners staff.
2.
Complete all critical barriers i.e. sheet rock, plywood,
2.
Vacuum work area with HEPA filtered vacuums.
6. Remove isolation of HVAC system in areas where work Is being
plastic, to seal area from non work area or implem I ent
3.
Wet mop/Wipe exposed surfaces with appropriately
control cube method (cart with plastic covering and
7. Remove barrier Materials carefully to minimize spreading of dirt and
labeled and BHSF approved hospital disinfectant.
before leaving work site or they can wear cloth or paper overalls that
sealed co work site with HEPA vacuum prior to exit)
4.
Contain: construction waste in tightly covered containers
8. Final cleaning by Environmental Services prior to occupancy.
before construction begins.
6. All personnel entering work site are required to wear shoe covers.
before transporting.
3.
Maintain negative air pressure within work site utilizing
5.
Cover transport receptacles or carts. Tape covering
area.
HEPA equipped air filtration units.
unless solid lid.
4.
Seal holes, pipes, conduits, and punctures
6.
Remove isolation of HVAC system in areas where work
appropriately.
is being performed.
5.
Construct anteroom and I require all personnel to pass
7.
Remove barrier materials carefully to minimize
I d cep_t_i`�;sIAddItIons to this area noted by attached memoranda.
through this room so they can be vacuumed using a
Contractor Agreed to Comply
spreading of dirt and debris associated with
By I Date:
HEPA vacuum cleaner before leaving Work site or.they
construction.
can wear cloth or paper overalls that are removed
8.
Fina , I cleaning by Environmental Services prior to
each time they leave the work site,
Occupancy.
6.
All personnel entering work site are required to wear
shoe covers. Shoe covers must be changed each time
orker exits the work area.
the worker`
7.
Contain construction waste in tightly covered
containers before transporting.
8.
Cover transport receptacles or carts. Tape covering
unless solid lid.
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Step 4:
Identify the areas surrounding the project area, assessing potential impact using the INFECTION
CONTROL RISK GROUP designation from Step Two.
El
Locatiomof Construction: 3 North Tower L&D
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Project Coordinator/Tel.: Luigi Ramudo
E Lateral
Wlmn
Superviso el.:
Yes
/No I
Construction Activity
Yes/No
Infection Control Risk Group
Type A: Inspection, non-invasive activity.
6
Group 1: Low Risk
3MUNIIIIIIIIIIII
Risk Group a
Group 2: Medium Risk
Type C: Activity generates moderate to high levels of dust, requires
x
Group 3: Medium/High Risk
I I
Step 6
Identify specific site of activities (e.g., patient rooms, medication room, etc.)
3rd floor of the north tower adjacent to the sterile corridor where there male and female restrooms
are located that are connected to the doctors lounge.
� tep 6
Identify issues related to: ventilation, plumbing, electrical in terms of the occurrence of probable outages.
Low, shut downs will be coordinated with end users and facility
Step 7
Consider potential risk of water damage. Is there a risk due to compromising elements of the building
envelope or structure? If so, what steps will be taken to keep water out of the building?
Very low plumbing work will have shut downs coordinated with all parties involved.
Step 8
Identify containment measures. Describe how the barriers will be constructed. Describe how negative
-57f filtration will be *,rovided? Attach draVi"
,s
if necessary.
Z-4inktnattin kaffta-?3
air machines running at all times. Sticky mats and damp clothes are to be utilized within the
containment area near opening.
Step 9
Work hours: Can the work be performed during off -peak hours? What will be your work schedule?
Normal working hours
Step 10
Discuss the following containment issues with the project team (comment as to how these will be
addressed):
Traffic flow - Low interruption
:Iousekeeping - Swept and damp mopped as often as needed by construction wor ers.
Debris removal - In covered carts to be cleaned upon re-entry into L&D
Step 11
Will air sampling be performed prior, during or after the project? Provide details of the air-monitoring plan.
NIA
Revised 10108 5 BHS 107 Agreement
EMT-T-11 I It r-1 1.7f 5TRXI
Project Name and Number: SMH NICU Operating Room I Permit No & Ex p. Date:
Locatiomof Construction: 3 North Tower L&D
I Project Start Date: TBD
Project Coordinator/Tel.: Luigi Ramudo
Estimated Duration: 2 months
Contractor Performing Work/Tel.:
Superviso el.:
Yes
/No I
Construction Activity
Yes/No
Infection Control Risk Group
Type A: Inspection, non-invasive activity.
6
Group 1: Low Risk
Type B: Small scale short duration, moderate to high levels.
INt
Group 2: Medium Risk
Type C: Activity generates moderate to high levels of dust, requires
x
Group 3: Medium/High Risk
greater I work shift for completion.
J
X
Type D: Major duration and construction activities requiring consecutive
Group 4• Highest Risk
I
work shifts.
During Construction or Renovation
Upon CompletionlPriorto Occupancy
1. Execute work by method to minimize raising dust from the
1. Wet mop/wipe exposed surfaces with appropriately labeled and BHSF
CO)
construction operations.
approved hospital disinfectant.
2. Immediately replace any ceiling the displaced for visual inspection.
J
1. Provides active means to prevent air -home dust from dispersing Into
1. Wet moptwipe exposed surfaces with appropriately labeled and BHSF
W
atmosphere.
approved label disinfectant.
2. Water mist work surfaces to control dust while cutting.
2. Contain construction waste before transport In tightly covered solid lid
3. Seat unused doors with duct tape.
containers.
4. Block off and seal air vents.
3. Wet mop and/or vacuum with HEPA filtered vacuum before leaving
5. Remove or Isolate HVAC system in area where work Is being done
work area.
to prevent contamination of the duct system.
4. Remove isolation of HVAC system in areas where work Is being
•
6. Place dust mat at entrance and exit of work area
performed.
CO)
7. Wipe surfaces with disinfectant.
•
Cornm.No: 11087.00
8. Cover transport receptacles or carts. Tape covering unless solid lid.
Date:
01/18/12
1. Remove and Isolate HVAC system In area where work Is being
1. Do not remove barriers from work area until completed project is
done to prevent contamination of the duct system.
thoroughly inspected by Owners staff.
2. Complete all critical barriers i.e. sheet rock, plywood, plastic, to seat
2. Vacuum work with HEPA filtered vacuums.
area from non work area or implement control cube method (cart
1 Wet mop/wipe exposed surfaces with appropriately labeled and BHSF
with plastic covering and sealed co work site with HEPA vacuum
approved hospital disinfectant.
prior to exit) before construction begins.
4. Contain construction waste In tightly covered containers before
0
0
3. Maintain negative air pressure within work site utilizing HEPA
transporting.
equipped air filtration units.
5. Cover transport receptacles or carts. Tape covering unless solid lid.
4. Contain construction waste in tightly covered containers before
6. Remove Isolation of HVAC system In areas where work Is being
transporting.
performed.
5. Cover transport receptacles or carts. Tape covering unless solid lid.
7. Remove barrier materials carefully to minimize spreading of dirt and
6. Seal holes, pipes, conduits and punctures appropriately
debris associated with construction.
8. Final cleaning by Environmental Services prior to occupancy.
1: Isolate HVAC system In area where work Is being done to prevent
1. Do not remove barriers for work area until completed project is
contamination of duct system.
Inspected by the Owner's staff.
2. Complete all critical barriers I.e, sheet rock, plywood, plastic, to seal
Z. work area with HEPA A-filtered vacuums.
area from non work area or Implement control cube method (cart
'Vacuum
3.: Wet moptmpe exposed surfaces with appropriately labeled and BHSF
with plastic, covering and sealed co work site with HEPA vacuum
approved hospital disinfectant.
prior to exit) before construction begins.
4. Contain construction waste In tightly covered containers before
3. Maintain negative air pressure Within work site utilizing HEPA
transporting.
>
equipped air filtration units.
5. Cover transport receptacles or carts. Tape, covering unless solid lid.
4, Seal holes, pipes, conduits, and punctures appropriately,
6. Remove isolation of HVAC system in areas where work Is being
ai
5. Construct anteroom and require all personnel to pass through this
performed.
room so they can be vacuumed using sing a HEPA vacuum cleaner
7. Remove barrier Materials carefully to minimize spreading of dirt and
before leaving work site or they can wear cloth or paper overalls that
debris associated with construction,
are removed each time they leave the work site.'
8. Final cleaning by Environmental Services prior to occupancy.
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 in tightly covered containers before
transporting.
8. Cover transport receptacles or carts. Tape covering unless solid lid.
Additional Requirements: Parties agree to Implement required precautions, notify the ICRA Team of necessary changes and Institute corrective actions Immedlatety should
violation of precautions be found. Contractor agrees to disseminate this Information to subcontractors and assume reN2nslbU for their compliance.
Date:
Initials: -:: ' Initials:
I d cep_t_i`�;sIAddItIons to this area noted by attached memoranda.
Requested By I Date:
Contractor Agreed to Comply
By I Date:
Facility's Manager I Date
AN
Infection Control Practitioner
By / Date:
Safe Officer/ Date:
Adapted with ton V. Kg!, nedy, B. Barnard, developed at St. Luke Episcopal Hospital, Houston, TX, ICRA Permit
Revised 10/08 8 BHS 107 Agreement
PRINTED 24X36 NOT TO SCALE
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Cornm.No: 11087.00
Date:
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