Patient safety during renovations

Health and safety of all; patients, visitors, staff and society in general is of utmost importance. Health and safety programmes must therefore be in place to protect patients, property, society as well as the environment, and at the same time also comply with applicable regulations and safety norms at all times.

In general, good hospital designs insist on considerable measures in the design aspect for safe practices. However, it is often observed that these safety designs and systems eventually are questionable when a hospital is under renovation or in for an expansion. It so happens that during such an activity, there is a tendency to neglect certain protocols and maybe even overlook certain opportunities of risks which may be bold and underlined but still submerged under the sea of additional renovation activities. These renovation/expansion activities have strong properties of being less visible and hence are overlooked or ignored, thereby presenting a greater risk to patients and staff and making the facility vulnerable to various safety issues.

Some examples of activities that impact the environment:

• Renovation of patient rooms or a running facility.
• Adding network cabling for fire control systems, nurse call/communication systems, TV systems/electrical system updates, etc.
• Installing or removing cabling above drop ceilings
• Adding new space/expansion – construction work
• Adding/repair/replacement of equipment with electronic cabling, plumbing and pneumatic systems.
• Removing ceiling tiles to access plumbing and cabling networks.
• Maintenance work like replacing ceiling tiles, etc.
• Demolition work like removal of pipes, electrical cables, etc.
• Remedial work like removal of asbestos or moulds, etc.
• Furniture repairs.
• Painting

Any kind of work of construction/renovation induces a noticeable percentage increase of dust particles in the environment, debris and other multiple wastes on floor and an impact full increase in the work population. All these are instrumental to many a risk opportunities for patient safety.

Some examples of possible impact due to repair/construction/renovation activities in hospital facilities:

• Renovation/construction/repair activities are generally executed by external parties (outsourced contractors). This results in an increase in number of people in the premises in comparison to the average population in a normal situation. Often these contractors assign workers on a daily basis tending to complications in identity and access security systems.
• Prolonged work results in ignorance of presence of these external workers in the routine systems and so the employees tend to be less alert, exhibiting another risk of easy access by an unidentified person and inducing risk opportunities like thefts, abduction, etc.
• These workers by and large work without health protective gears; they may be using protective gears against physical harm in terms of injuries/ accidents, etc.; but not following any measures to protect themselves from hospital acquired infections (HAI), etc. Thereby becoming an important open channel of HAI and health risks thereof.
• Some renovation/construction/repair activities are likely to create particles that tend to remain suspended in the air (aerosolised). For e.g;. a commonly found fungus Aspergillus spp in indoor environments feeds on dirt and dust particles and cellulose-based building materials, resulting in patients with suppressed immune systems susceptible to developing a potentially life-threatening infection “aspergillosis”
• Construction/renovations results in additional noise in the environment that discourages patient comfort and employee stress levels too.
• Renovation/repair activities generate a negative impact on smooth functioning of daily activities and may result in negligence in following important safety protocols. For e.g. skipping a routine housekeeping/cleaning protocol or handling of waste protocol, information management and confidentiality protocol, etc.
• Often there are temporary shifts of departments or services during renovations/repairs that creates confusion amongst patients, relatives and staff thereby inhibiting traffic control within the hospital.
• Extra work hours and changes in shifts tend to stress the employees and create employee dissatisfaction scenarios.
• Renovations and repair jobs often leave a lot of unwanted objects on the floor or by the wall that effect the transportation and internal mobility of the hospital. Spills, plumbing breaks, water leaks/gas leaks, etc also affect similarly.
• There may be a risk of disruption of a particular service like electrical failure/ water supply (water contamination) or food contamination/medical gas supply issues, etc., and impact smooth functioning.
• Any power fluctuations and load impacts due to ongoing work may damage the medical equipment or computers installed.
• Finally all renovations/ repairs/expansions during care delivery in a running and occupied hospital does have an unfavourable impact on the image of a hospital.

Exploring some safety determinants during renovations/expansions in a running hospital; I identified 10 crucial safety considerations:

• Infection control
• Dust and debris control
• Waste disposals
• Drug pilferage control, theft and abduction control
• Health hazard control
• Noise control
• Information management
• Employee safety
• Infrastructure damage control
• Image damage control.

Steps that can be taken to control dust and airborne particles that impact an environment and infection control:

• Execute work methods that minimise raising dust from construction/repair work.
• Install barriers to prevent dust from entering patient-care areas.
• Ensure that these barriers are in compliance with local fire codes and are impermeable to fungal spores.
• All windows and outside doors should remain closed, to preclude the bypass of unfiltered air. Windows or openings to the work area may be open if the windows are within the site barriers and the bypass of air to other patient area is prohibited.
• Use prefabricated plastic containment systems/plastic sheets to control dust, wherever necessary.
• Use HEPA vacuums to clean surfaces.
• Take adequate measures to prevent airborne dust from dispersing into HVAC and the atmosphere.
• Instil enclosures with negative pressure to control dust within and HEPA filtration in work areas adjacent to patient areas for proper air filtration and use exhaust systems to directly exhaust air outside.
• Implement measures to ensure full particle containment.
• If an activity involves the possibility of exhuming fumes or vapours in or near the patient area the contractor should notify the hospital engineering team and safety team to preclude the exposure of patients, visitors, and staff.
• Ensure immediate repairs of openings/breaks in walls, window frames, etc., to preserve fire/smoke protection barriers and a clean environment.
• Ensure optimal maintenance of all engineering controls.
• Ensure immediate repairs of water leaks if any because it can become reservoirs for fungus.
• Document, record and monitor pressure conditions between contained work areas and adjacent atmospheres. Instil a system to measure and monitor airborne particle counts before, during and after the activities.
• Air scrubber can be installed in large containment areas to control airborne particles and environmental dispersions.

Hospital employees understand infection control policies and are trained in methodologies and measures to be taken for infection control in a hospital environment, to not only ensure patient safety but also personal health safety. However, the construction workers/external labourers that work during construction/repair/renovation work may not be trained nor sensitised on issues like HAI / health and safety /patient safety, etc.

Ways and measures to take to address this specific safety issue:

• Implement effective infection control monitoring systems.
• Deploy an inspection team that inspects the area to determine possible infection risk to construction workers prior to the start of the project and instils adequate measures to remove these hazards prior to initiation of the projects.
• This inspection team should continue to monitor and control the risk assessments defined and identified.
• Emphasise that construction workers, if sick with a potentially contagious sickness, do not report to duty.
• Explicitly specify and encourage use of PPE (personal protective equipment) by construction workers wherever necessary for their health safety.
• Encourage a system of monitoring radiation impacts and safety precautions for workers exposed to radiation while working in such areas.
• Sensitise and orient workers on safe handling of needles or sharps or medical devices found during construction.
• Instil a system of reporting and precautions thereof for any potential risk exposure (for; e.g. needle prick/sharp injury/cold and flu at work, etc.)
• Implement a friendly atmosphere for effective communication of problems and issues pertaining to the project to ensure efficient and safe practices.
• There is no harm in conducting a two hour sensitisation workshop amongst these workers prior to the project start to orient them to safe practices in line with hospital safety practice, to not only ensure an effective project execution but also safety of workers, staff, patients and the hospital environment.

The above steps for workers’ health safety and dust control measures, address the major concern of hospital-acquired infections (HAI) and dust free hospital environment, to ensure good infection control and patient safe practices during construction/renovations/repairs in a running hospital.

Some other aspects of safety concerns can be addressed by taking the following steps:

• The infection control team with the kitchen team and the engineering team must ensure safe water supply and clean cooking areas and take adequate measures to avoid any water/food contamination.
• Safety aspects like security for thefts/abduction, pilferage, etc. can be addressed by instilling a tight security system with CCTVs and worker identity badges, gate passes for entry and exit of materials/equipment, etc.
• Encourage contractors to deploy the same work force every day to avoid any identity confusions and variations.
• High technology use like RFID can also be installed for efficient tracking and alert systems. Tech-savvy hospitals have also installed biometrics for appropriate identification of patients, staff and other workers.
• The infection control team with the housekeeping team can sensitise and implement an additional waste disposal system during renovation / construction/repair activities; that specially take care of the additional waste generated and also ensure the routine practices of hospital waste management systems, by all.
• The hospital engineering team must also implement an inspection plan for infrastructural damage and repairs if any during the project execution.
• Implement an additional medical equipment maintenance plan to ensure regular cleaning, maintenance and safe use of medical equipment for optimal uptime.
• Noise control is also an important aspect to consider for patient comfort, necessitating the engineering team to take adequate measures for the same.
• All employees including construction workers should be sensitised on confidentiality and information security steps to be followed in advent of coming across/handling any patient record/ information.
• The hospital engineering team, safety team, infection control team and the contractor’s representative should deliberate a risk mitigation plan before the initiation of any renovation/construction/maintenance project. This plan can indicate the task to be done, the area of work, the impact/potential risks and precautions to be taken.
• The safety team can then continuously measure, monitor, evaluate and control all safety issues that may arise. If the precautionary steps were already identified, it can be evaluated and improvised and if any unpredicted event occurs, the plan could be revised for further improvisations.
• Document, record all occurrences and corrections and comply with all applicable regulations at all times.

With such an active initiative the hospital management/administration not only portrays a sense of responsibility and accountability but also besets safe practices to ensure patient safety, employee safety and infrastructure safety at all times. The initiative positively influences image damage control and also sets an example of responsible business citizens.