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Definitions and elements
Definition: An ICRA is multidisciplinary, organizational, documented process that after considering the facility's patient population and program:
- Focuses on reduction of risk from infection,
- Acts through phases of facility planning, design, construction, renovation, facility maintenance, and
- Coordinates and weighs knowledge about infection, infectious agents, and care environment, permitting the organization to anticipate potential impact.
The ICRA elements required for consideration are located in Chapter 1.5 of the 2006 AIA Guidelines. In the 2006 edition, the ICRA elements are divided into three areas: processes for design, construction, and mitigation.
The design area requires "long-range planning" for new or renovated buildings and adds a new element "finishes and surfaces" a critical feature over the lifetime of the facility. Considerations include:
- Number, location, and type of airborne infection isolation and protective environment rooms.
- Location of special ventilation and filtration such as emergency department waiting and intake areas.
- Air handling and ventilation needs in surgical services, airborne infection isolation and protective environment rooms, laboratories, local exhaust systems for hazardous agents, and other special areas.
- Water systems to limit Legionella sp. and other waterborne opportunistic pathogens.
- Finishes and surfaces.
The building and site areas anticipated to be affected by construction shall include consideration of the following:
- Impact of disrupting essential services to patients and employees.
- Determination of the specific hazards and protection levels for each.
- Location of patients by susceptibility to infection and definition of risks to each.
- Impact of potential outages or emergencies and protection of patients during planned or unplanned outages, movement of debris, traffic flow, cleanup, and testing and certification.
- Assessment of external as well as internal construction activities.
- Location of known hazards.
Infection Control Risk Mitigation
The mitigation recommendations from the ICRA panel shall address the following:
- Patient placement and relocation.
- Standards for barriers and other protective measures required to protect adjacent areas and susceptible patients from airborne contaminants.
- Temporary provisions or phasing for construction or modification of heating, ventilating , air conditioning and water supply systems.
- Protection from demolition.
- Measures taken to train hospital staff, visitors and construction personnel.
Finally, the ICRA panel must inspect the installation of infection control measures and provide continuous monitoring of their effectiveness throughout the project. The monitoring may be conducted by in-house infection control and safety staff or by independent consultants. Provisions must contain written procedures for emergency suspension of work, indicating responsibilities of each party—owner, designer, constructor and monitor.
Numerous resources are available to assist organizations with development and implementation of an ICRA. This includes ASHE/AIA workshops and other professional organizations that provide continuing education on the topic. See Links.
Tools and resources
The ICRA matrix is a published assessment method that is widely accepted by engineers and architects, and is one effective method for completing an ICRA. Although the ICRA does not have to be done as a matrix, it does help non-clinical staff understand management of patient groups without requiring specific diagnoses.
Each facility should categorize patients per group within a specific patient population. The development of the "patient risk groups" is quite relative--and the criteria are dependent on the facility's mix of patients. Nursing homes and ambulatory care delivery sites have very different populations, and risk is relative.
The key principle used for categorizing patients considers:
- Inherent susceptibility to infection – immunosuppression due to chemotherapy, radiation, such as bone marrow allograft patients, who as a group remain at greatest risk.
- Invasiveness – a healthy patient undergoing surgery is at greatest risk when sterile issues are exposed to the OR environment.
- The key principle for classifying projects is determining the degree of dust created.
- The patient groups are matched with project categories to select the level of required precautions.
- Consideration of pre-construction, demolition, intra-construction, post construction and cleanup activities as well as educational and monitoring needs, before, during and after construction/renovation.
- AIA and JCAHO require documentation of the ICRA. One component of the ICRA may be submission of an “infection control permit” or “project approval signature block”.
The construction matrix tool includes a sample permit which follows the format of the matrix, assessing patient risk categories and environmental risk groups to determine appropriate class or level of precautions.
- Matrix of precautions for construction and renovation - color 2009 (.pdf) (89KB)
- Matrix of precautions for construction and renovation - color 2009 (.doc) (110 KB)
The ICRA matrix as described above and promoted by the the Association for Professionals in Infection Control and Epidemiology (APIC) and the American Society for Healthcare Engineering (ASHE) is available in 2 training videos; one directed to healthcare professionals and one for construction personal, with availability in English and Spanish. Go to www.EnvisionInc.net.
Airborne, biologic, chemical and radiologic building protection
- NIOSH guidance for protecting building environments from airborne chemical, biological, or radiological attack (1.1 MB)
- NIOSH guidance -filtration and air cleaning systems to protect building environments (951 KB)
ASHRAE Building protection (220 KB)
Guidance for new and existing buildings regarding protection of air, water, and food systems within buildings.
- Army Corps of Engineers: Protecting buildings and their occupants from airborne hazards (79 KB)