Have you built infection prevention into the design of your construction or renovation project? Construction activities - even such minor jobs as installing T1 lines, removing ceiling tiles and working on your HVAC ducts - can disperse dirt, dust, bacteria and sometimes even fungal spores into the environment. If inhaled, these may cause severe infection in patients with immune systems compromised by surgery. Here are four construction projects, and the precautions to take for each.

1. Freshening up the lobby
The admit area needs a new coat of paint to liven it up. It's a simple, in-and-out job, and that's why it's considered a type A construction project - inspection or non-invasive activities.

Yes, outpatient surgery patients will be coming through there, as will whoever is accompanying them. But the lobby is considered an office area. It is not sterile, nor is it connected to any sterile area. Therefore, everyone is considered to be part of the low-risk patient group.

While you will need to keep the lobby well ventilated, there are few other precautions needed, as those doing the work shouldn't need to enter your facility's sterile and sub-sterile areas in order to complete the job. Signs and good communication will keep patients and families from worrying that this work will compromise the surgical area and affect them.

Precautions you should take during construction:

• Ensure the work is executed by methods that minimize dust and dirt related to the work.

Upon completion:

• Clean up the work area.

2. A fancy monitor in the endoscopy suite
Your physicians like toys, so they decide to get some ceiling-mounted LCD screens for the endoscopy suites. Any time you have to open the ceiling, you may be interfering with the HVAC system, which poses the risk of circulating construction dust throughout your facility. Ceiling-mounted monitors, booms, major cabling activities, and minor duct or electrical work are among the construction activities considered type C construction.

Because some endo suites are used for procedures and not invasive surgery (air exchange requirements are less stringent, and procedure rooms don't have to be on a sterile corridor, for example), patients are medium-risk. Pain practice patients would also fall into this category. The combination of medium-risk patients and type C construction calls for class III procedures.

Precautions you should take during construction:

• Isolate the HVAC system in the area where the work is being performed.
• Before construction begins, complete all critical barriers (sheetrock, plywood or plastic) to seal the area from non-construction areas or implement an anteroom connected to the work site, using a HEPA vacuum for vacuuming workers' clothing before exit.
• Maintain negative air pressure within the work site, utilizing HEPA-equipped air filtration units.
• Contain construction waste before transport, which should be done using tightly covered containers.
• Cover transport receptacles or carts using tape unless there is a solid lid.

Upon completion:

• Don't remove barriers from the work area until the safety and infection control departments inspect the completed project.
• Remove barrier materials carefully to minimize spreading dirt and debris.
• Vacuum the work area with HEPA-filtered vacuums.
• Wet mop work area surfaces with disinfectant.
• Return ventilation to the areas where the work has been performed.
• Have environmental services thoroughly clean the area.

3. Digitizing your ORs
You've decided to enter the digital age and put computer stations in the ORs - enhancing and easing record-keeping and information transfer. Even small-scale, short-duration activities like installing computer cabling are cause for special precautions.

The OR is a step up from the endoscopy procedure room in our last example, and the patients hosted in your outpatient ORs are considered high-risk. Although it may appear that putting in the computer cables is likely only to cause minimal dust - and therefore considered type B construction - you need to carefully consider the amount of dust production and whether this activity may actually be type C.

Precautions you should take during construction:

• Minimal dust will be generated if no drilling is required. However, even if only minor drilling is needed and dustless drills are used to minimize dispersal, the area must be separated from clean and sterile corridors - even if the project's length will be brief. Pre-framed plastic barriers sealed into place can separate the work area from the clean area.
• Block off and seal air vents.
• Place a dust mat at the entrance and exit of the work area.

Upon completion:

• Wipe work surfaces with disinfectant.
• Contain construction waste before transport using tightly covered containers.
• Wet mop and vacuum with HEPA-filtered vacuum before leaving work area.
• Remove the barriers and re-clean.

4. Inspecting ceiling tiles in central sterile
You should be monitoring areas including tiles for stains or signs of leaks. Visual checks for stains may be clues that mold or fungus is taking root, and serious problems may be prevented if caught in time. Even though this activity is considered type A, the location in this example is the key.

Central sterile supply needs to be maintained as clean as possible, or you could end up compromising all your patients with contaminated materials. Despite the minor nature of the activity, central sterile is considered a high-risk area, and you should err on the side of caution by engaging in stringent class IV precautions.

Because a visible stain may actually represent a very large area of mold above the ceiling, the very act of pushing the tile up could disturb the mold, disperse it into the area and cause major contamination - at which point it's beyond control. This should be considered Class IV under such a circumstance.

Precautions you should take during construction:

• If a special containment cube is sealed up tight against the ceiling with a HEPA machine connected to it, you have essentially created the proper barrier and negative pressure needed to contain the contamination. Workers entering the ceiling should be properly protected.
• Any tiles removed should be carefully bagged and the area cleaned.

Upon completion:

• Carefully remove barrier material.
• Put waste in tightly covered containers before transport.
• Cover carts for transporting waste.
• Vacuum with HEPA-filtered vacuum before leaving work area.
• Wet mop with disinfectant.

Apply the matrix
Ultimately, the goal is to keep dust and dirt inside the work area and keep the patient or support area clean. This isn't simply a matter of paper or plastic barriers - the precautions you take must be strong enough to hold up for the work and length of time needed to complete the project.

As you can see from examples three and four, the matrix is just a starting point of how to assess the risk for patients - not everything fits the matrix perfectly. The key is empirically determining the extent of your actions. Gauge the risk of infectious agents' being released, and take steps from there to contain dust and debris so as not to expose patients and clean areas to them.