Ask DONNA

Use an ICRA in health-care construction projects

Recently, I have had several calls that have started like this:

"I have been cabling in hospitals for years. Now they are handing me an 'ICRA binder' full of 'new safety requirements' and telling me it is this way or the highway. Why the sudden interest in ICRA? What happened? Can you help?"

First, it really has not been sudden. And second, people are dying.

Can I help? Well, that depends on your definition of "help." These "new safety requirements" are not going away. If you are going to design and install information-transport systems in health-care facilities in the future, you need to understand the rules associated with an ICRA-infection control risk assessment.

Meet the rulemakers

In 1986, at the American Society for Healthcare Engineering (ASHE) of the American Hospital Association (AHA) Conference and Exhibition on Health Facility Planning, Design, and Construction (PDC), an engineer from the Centers for Disease Control and Prevention (CDC) warned of the dangers of mold spores in the dust above the ceilings and legionella bacteria in the water. Legionella bacteria is the cause of Legionnaires' Disease.

From 1986 to 1996, safety requirements were largely shouldered (or not) by the project architect and his/her team of design professionals. It is interesting to note that this was also about the time when we, as telecommunications design professionals, were struggling to get a seat at the table early in the project design-like before "substantial completion" where "the team" would realize that there wasn't any cabling for networking or cable television and then call us in a panic.

Within the last 10 years, the American Institute of Architects (AIA), CDC, and Joint Commission for Accreditation of Health Care Organizations (JCAHO) have all begun publishing guidelines to help owners, design professionals, and contractors prevent the spread of contaminants and pathogens during renovation and construction projects.

In April 2001, the AIA and the Facility Guidelines Institute introduced the 2001 edition of Guidelines for Design and Construction of Hospital and Health Care Facilities. The AIA Guidelines, as they are commonly called, set minimum program, space, and equipment requirements for clinical and support areas of hospitals, nursing homes, freestanding psychiatric facilities, outpatient and rehabilitation facilities, and long-term care facilities. The AIA Guidelines also established minimum engineering design criteria for plumbing, medical gas, electrical, heating, ventilating, and air-conditioning systems. The information transport system (ITS) is also covered within these various sections.

As is the case with most standards, the AIA Guidelines 2004 is now in revision. The 2006 draft of the AIA Guidelines just completed public review for comment and should be published soon. For additional information, see www.aia.org.

AIA Guidelines was then referenced (read that: made mandatory) by the Joint Commission on Accreditation of Healthcare Organizations in the Environment of Care Standard. For additional information, see www.jcaho.com.

Other organizations with a role in infection control include the Association for Professionals in Infection Control and Epidemiology (APIC), the CDC, and the Health Care Infection Control Practices Advisory Committee (HICPAC). The CDC and HIPAC have issued a document entitled the Guideline for Environmental Infection Control in Healthcare Facilities, 2003. For additional information or to download the document, see www.cdc.gov.

So, what is this ICRA?

The ICRA can best be described as a strategic plan to identify and mitigate potential risk for transmission of bacteria that could be spread during a construction or renovation project.

The process for developing the ICRA should begin during the project's programming phase. The owner of the facility is responsible for assembling a panel with expertise in the areas of infection control, risk management, facility design, safety epidemiology, ventilation, and construction.

It is unlikely that we would be asked to sit on such a panel, but we need to understand the panel's function.

The ICRA panel will then address the impact the particular construction project will have on the patient population. The plan that is adopted by the ICRA panel is meant to be a living document that will be updated through each phase of the project. During the actual construction, the panel should meet on a regular basis to update the ICRA and to assess the risk as construction progresses.

Educating the ICRA panel on fundamental ITS design concepts and code requirements is often overlooked, while more visible issues, such as construction barriers, are discussed at length. The designer should also convey to the owner and ICRA panel how the IT systems are intended to function once construction is complete, and how the various systems will operate during the different phases of construction.

The Matrix, and TIA

As amazing as it may seem, there is no written guideline that defines how an ICRA should be documented. This could explain why contractors complain that the ICRA documentation they receive is woefully inadequate. Currently, the de facto standard for documentation is the ICRA Matrix and an Infection Control Construction Permit. Excellent examples of these can be downloaded from www.premierinc.com. Premier is an alliance of not-for-profit hospitals and health-care systems.

At the TIA TR-42.1's June 2004 meeting, the subcommittee formed a task group to look at the unique requirements for structured cabling within a health-care environment. The group's mission is to determine the changes, modifications, and/or additions necessary to address structured cabling within health-care facilities within their current family of standards. Once their review is complete, and all of the issues are identified, the task group will make a recommendation to TR-42.1 relative to further work on a document.

The most important thing: Life

The purpose of performing ICRAs and implementing work practices is to reduce the risk, or eliminate the transmission of, pathogens in the indoor environment. It is very important that we as designers:

• Understand the construction project and processes, and the building systems;

• Remain mindful of potential sources of contaminants, including those that are outside the "construction zone," such as electrical or communications trenching;

• Have emergency procedures in place to address things that can go wrong, such as failure of negative air pressure enclosure.

It may seem like a lot to think about, but the following facts speak volumes as to why it is necessary:

• There are about 5,500 hospitals in the United States, and 75% of all construction projects involve an expansion or renovation of an existing hospital.

• About 2.1 million nosocomial (hospital-acquired) infections afflict patients annually, costing the health-care industry approximately $3 billion annually.

• In 2000, about 103,000 deaths resulted from nosocomial infections, and it has been estimated that 5,000 of those deaths were related to construction.

I believe that, as an industry, our motto should be, "Helping to ensure patient safety through good design and installation practices." Will you join me?

DONNA BALLAST is BICSI's standards representative, and a BICSI registered communications distribution designer (RCDD). Send your questions to Donna via e-mail: [email protected]