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Microorganisms and biologicals identified as select agents Ventilation requirements for areas affecting patient care in hospitals and outpatient facilities Pressure relationships and ventilation of certain areas of nursing facilities Filter efficiencies for central ventilation and air conditioning systems in general hospitals Filter efficiencies for central ventilation and air conditioning systems in outpatient facilities Filter efficiencies for central ventilation and air conditioning systems in nursing facilities Filter efficiencies for central ventilation and air conditioning systems in psychiatric hospitals Microorganisms isolated from arthropods in health-care settings Department of Health and Human Services duck hepatitis B virus deoxyribonucleic acid dioctylphthalate U.

Department of Agriculture U. Department of Health and Human Services. References to non-CDC sites on the Internet are provided as a service to the reader and does not constitute or imply endorsement of these organization s or their programs by CDC or the U.

CDC is not responsible for the content of pages found at these sites. Chinn received no research funds from commercial sources either directly, or indirectly through awards made to the hospital, before or during the development of these guidelines.

Paul, MN Ramon E. Lin, PhD U. Shannon E. Attention is given to engineering and infection-control concerns during construction, demolition, renovation, and repairs of health-care facilities.

Use of an infection-control risk assessment is strongly supported before the start of these or any other activities expected to generate dust or water aerosols.

Also reviewed in Part I are infection-control measures used to recover from catastrophic events e. Part II of this guideline, Recommendations for Environmental Infection Control in Health-Care Facilities, outlines environmental infection control in health-care facilities, describing measures for preventing infections associated with air, water, and other elements of the environment.

The topics addressed in this guideline are applicable to the majority of health-care venues in the United States.

This document is intended for use primarily by infection-control professionals ICPs , epidemiologists, employee health and safety personnel, information system specialists, administrators, engineers, facility managers, environmental service professionals, and architects for health-care facilities.

Key recommendations include a infection-control impact of ventilation system and water system performance; b establishment of a multidisciplinary team to conduct infection-control risk assessment; c use of dust-control procedures and barriers during construction, repair, renovation, or demolition; d environmental infection-control measures for special care areas with patients at high risk; e use of airborne particle sampling to monitor the effectiveness of air filtration and dust-control measures; f procedures to prevent airborne contamination in operating rooms when infectious tuberculosis [TB] patients require surgery; g guidance regarding appropriate indications for routine culturing of water as part of a comprehensive control program for legionellae; h guidance for recovering from water system disruptions, water leaks, and natural disasters [e.

Whenever possible, the recommendations in Part II are based on data from well-designed scientific studies. However, certain of these studies were conducted by using narrowly defined patient populations or for specific health-care settings e.

Construction standards for hospitals or other healthcare facilities may not apply to residential home-care units.

Similarly, infection-control measures indicated for immunosuppressed patient care are usually not necessary in those facilities where such patients are not present.

Other recommendations were derived from knowledge gained during infectious disease investigations in health-care facilities, where successful termination of the outbreak was often the result of multiple interventions, the majority of which cannot be independently and rigorously evaluated.

This is especially true for construction situations involving air or water. Other recommendations are derived from empiric engineering concepts and may reflect an industry standard rather than an evidence-based conclusion.

Where recommendations refer to guidance from the American Institute of Architects AIA , the statements reflect standards intended for new construction or renovation.

Existing structures and engineered systems are expected to be in continued compliance with the standards in effect at the time of construction or renovation.

Also, in the absence of scientific confirmation, certain infection-control recommendations that cannot be rigorously evaluated are based on a strong theoretical rationale and suggestive evidence.

Finally, certain recommendations are derived from existing federal regulations. Infections caused by the microorganisms described in these guidelines are rare events, and the effect of these recommendations on infection rates in a facility may not be readily measurable.

Therefore, the following steps to measure performance are suggested to evaluate these recommendations Box 1 : Box 1.

Environmental infection control: performance measures 1. Monitor and document daily the negative airflow in airborne infection isolation AII rooms and positive airflow in protective environment PE rooms, especially when patients are in these rooms.

Perform assays at least once a month by using standard quantitative methods for endotoxin in water used to reprocess hemodialyzers, and for heterotrophic and mesophilic bacteria in water used to prepare dialysate and for hemodialyzer reprocessing.

Such policies should result in either repair and drying of wet structural or porous materials within 72 hours, or removal of the wet material if drying is unlikely with 72 hours.

These topics are mentioned only if they are important in minimizing the transfer of pathogens to and from persons or equipment and the environment.

Although the document discusses principles of cleaning and disinfection as they are applied to maintenance of environmental surfaces, the full discussion of sterilization and disinfection of medical instruments and direct patient-care devices is deferred for inclusion in the Guideline for Disinfection and Sterilization in Health-Care Facilities, a document currently under development.

Working drafts of the guideline were reviewed by CDC scientists, HICPAC committee members, and experts in infection control, engineering, internal medicine, infectious diseases, epidemiology, and microbiology.

All recommendations in this guideline may not reflect the opinions of all reviewers. Part I. Introduction The health-care environment contains a diverse population of microorganisms, but only a few are significant pathogens for susceptible humans.

Microorganisms are present in great numbers in moist, organic environments, but some also can persist under dry conditions.

Although pathogenic microorganisms can be detected in air and water and on fomites, assessing their role in causing infection and disease is difficult.

Eight criteria are used to evaluate the strength of evidence for an environmental source or means of transmission of infectious agents Box 2.

An example of this application is the identification of a pathogen e. The presence of the pathogen does not establish its causal role; its transmission from source to host could be through indirect means e.

Box 2. The organism can survive after inoculation onto the fomite. The organism can be cultured from in-use fomites.

The organism can proliferate in or on the fomite. Some measure of acquisition of infection cannot be explained by other recognized modes of transmission.

Retrospective case-control studies show an association between exposure to the fomite and infection. Prospective case-control studies may be possible when more than one similar type of fomite is in use.

Prospective studies allocating exposure to the fomite to a subset of patients show an assication between exposure and infection.

Decontamination of the fomite results in the elimination of infection transmission. Box 3. The presence of the susceptible host is one of these components that underscores the importance of the health-care environment and opportunistic pathogens on fomites and in air and water.

As a result of advances in medical technology and therapies e. Trends in health-care delivery e. According to the American Hospital Association AHA , in , the number of hospitals in the United States totaled 6,; these hospitals had a total of 1,, beds,14 representing a 5.

Those patients remaining in acutecare facilities are likely to be those requiring extensive medical interventions who therefore at high risk for opportunistic infection.

The increasing age of hospitals and other health-care facilities is also generating ongoing need for repair and remediation work e.

Aging equipment, deferred maintenance, and natural disasters provide additional mechanisms for the entry of environmental pathogens into high-risk patient-care areas.

Increasingly, however, because of the growth in the number of susceptible patients and the increase in construction projects, the involvement of hospital epidemiologists and infection-control professionals is required.

The following are examples of adverse outcomes that could have been prevented had such experts been involved in the planning process: a transmission of infections caused by Mycobacterium tuberculosis, varicella-zoster virus VZV , and measles i.

The purpose of this guideline is to provide useful information for both health-care professionals and engineers in efforts to provide a safe environment in which quality health care may be provided to patients.

The recommendations herein provide guidance to minimize the risk for and prevent transmission of pathogens in the indoor environment.

Specific engineering parameters for these care areas are discussed more 6 fully in the text. The air in an AII room is preferably exhausted to the outside, but may be recirculated provided that the return air is filtered through a high efficiency particulate air HEPA filter.

The use of personal respiratory protection is also indicated for persons entering these rooms. Protective Environment PE is a specialized patient-care area, usually in a hospital, with a positive airflow relative to the corridor i.

Immunocompromised patients are those patients whose immune mechanisms are deficient because of immunologic disorders e.

Immunocompromised patients who are identified as high-risk patients have the greatest risk of infection caused by airborne or waterborne microorganisms.

Patients in this subset include those who are severely neutropenic for prolonged periods of time i.

Air 1. Modes of Transmission of Airborne Diseases A variety of airborne infections in susceptible hosts can result from exposures to clinically significant microorganisms released into the air when environmental reservoirs i.

Once these materials are brought indoors into a health-care facility by any of a number of vehicles e. Respiratory infections can be acquired from exposure to pathogens contained either in droplets or droplet nuclei.

Exposure to microorganisms in droplets e. Because these agents primarily are transmitted directly and because the droplets tend to fall out of the air quickly, measures to control air flow in a health-care facility e.

Strategies to control the spread of these diseases are outlined in another guideline. These particles can a contain potentially viable microorganisms, b be protected by a coat of dry secretions, c remain suspended indefinitely in air, and d be transported over long distances.

The microorganisms in droplet nuclei persist in favorable conditions e. Pathogenic microorganisms that can be spread via droplet nuclei include Mycobacterium tuberculosis, VZV, measles virus i.

With this enhanced buoyancy, the spores, which resist desiccation, can remain airborne indefinitely in air currents and travel far from their source.

Aspergillosis and Other Fungal Diseases Aspergillosis is caused by molds belonging to the genus Aspergillus.

Aspergillus spp. Clinical and epidemiologic aspects of aspergillosis Table 1 are discussed extensively in another guideline.

Patient-care items, devices, and equipment can become contaminated with Aspergillus spp. Table 2. Many of these fungi can proliferate in moist environments e.

Some fungi e. Environmental fungal pathogens: entry into and contamination of the healthcare facility Implicated environmental vehicle References Aspergillus spp.

Air filter False ceilings Heliport 20, 97 Scedosporium spp. Construction 9 Table 2. Rotting cabinet wood, pipe leak Ventilation duct fiberglass insulation Air filters Topical anesthetic 21 Acremonium spp.

Air filters Cladosporium spp. Pigeons, their droppings and roosts are associated with spread of Aspergillus, Cryptococcus, and Histoplasma spp.

There have been at least three outbreaks linked to contamination of the filtering systems from bird droppings98, , Pigeon mites may gain access into a health-care facility through the ventilation system.

Substantial numbers of these infectious particles have been associated with chicken coops and the roosts of blackbirds.

After the earthquake centered near Northridge, California, the incidence of coccidioidomycosis in the surrounding area exceeded the historical norm.

Recent studies have examined the presence of P. At present, specific modifications to ventilation systems to control spread of PCP in a health-care facility are not indicated.

Current recommendations 10 outline isolation procedures to minimize or eliminate contact of immunocompromised patients not on PCP prophylaxis with PCP-infected patients.

Tuberculosis and Other Bacterial Diseases The bacterium most commonly associated with airborne transmission is Mycobacterium tuberculosis.

A comprehensive review of the microbiology and epidemiology of M. Table 3. These organisms can be shed from heavily colonized persons and discharged into the air.

Airborne dispersal of S. Other gram-positive bacteria linked to airborne transmission include Bacillus spp. Outbreaks and pseudo-outbreaks have been attributed to Bacillus cereus in maternity, pediatric, intensive care, and bronchoscopy units; many of these episodes were secondary to environmental contamination.

The main exception is Acinetobacter spp. In one epidemiologic investigation of bloodstream infections among pediatric patients, identical Acinetobacter spp.

Exposure to these organisms is through direct inhalation. However, because water is the source of the organisms and exposure occurs in the vicinity of the aerosol, the discussion of the diseases associated with such aerosols and the prevention measures used to curtail their spread is discussed in another section of the Guideline see Part I: Water.

Airborne Viral Diseases Some human viruses are transmitted from person to person via droplet aerosols, but very few viruses are consistently airborne in transmission i.

Consequently, infection-control measures used to prevent spread of these viral diseases in health-care facilities primarily involve patient isolation, vaccination of susceptible persons, and antiviral therapy as appropriate rather than measures to control air flow or quality.

The factors facilitating airborne distribution of these viruses in an infective state are unknown, but a presumed requirement is a source patient in the early stage of infection who is shedding large numbers of viral particles into the air.

Airborne transmission of measles has been documented in health-care facilities. An outbreak of a Norwalk-like virus infection involving more than staff personnel over a 3-week period was investigated in a Toronto, Ontario hospital in ; common sources e.

Current CDC guidelines recommend negative-pressure rooms with anterooms for patients with hemorrhagic fever and use of HEPA respirators by persons entering these rooms when the patient has prominent cough, vomiting, diarrhea, or hemorrhage.

If an anteroom is not available, portable, industrial-grade high efficiency particulate air HEPA filter units can be used to provide the equivalent of additional air changes per hour ACH.

Potential for airborne transmission increases with patients who are effective disseminators present in facilities with low relative humidity in the air and faulty ventilation.

The American Institute of Architects AIA has published guidelines for the design and construction of new health-care facilities and for renovation of existing facilities.

These AIA guidelines address indoor air-quality standards e. More than 40 state agencies that license health-care facilities have either incorporated or adopted by reference these 14 guidelines into their state standards.

JCAHO, through its surveys, ensures that facilities are in compliance with the ventilation guidelines of this standard for new construction and renovation.

Figure 1. Air is conditioned for temperature and humidity before it enters the occupied space as supply air.

Infiltration is air leakage inward through cracks and interstitial spaces of walls, floors, and ceilings. Exfiltration is air leakage outward through these same cracks and spaces.

Return air is largely exhausted from the system, but a portion is recirculated with fresh, incoming air.

A centralized HVAC system operates as follows. The air enters the distribution system for conditioning to appropriate temperature and humidity levels, passes through an additional bank of filters for further cleaning, and is delivered to each zone of the building.

After the conditioned air is distributed to the designated space, it is withdrawn through a return duct system and delivered back to the HVAC unit.

Air from rooms housing tuberculosis patients is exhausted to the outside if possible, or passed through a HEPA filter before recirculation.

Filtration i. Filter Types and Methods of Filtration Filtration, the physical removal of particulates from air, is the first step in achieving acceptable indoor air quality.

Filtration is the primary means of cleaning the air. Five methods of filtration can be used Table 5. Particles collide with filter fibers and remain attached to the filter.

Fibers may be coated with adhesive. Particles enter into the filter and become entrapped and attached to the filter fibers.

Small particles, moving in erratic motion, collide with filter fibers and remain attached. Particles bearing negative electrostatic charge are attracted to the filter with positively charged fibers.

The second filter bank usually consists of high-efficiency filters. This filtration system is adequate for most patient-care areas in ambulatory-care facilities and hospitals, including the operating room environment and areas providing central services.

HEPA filters are at least As a reference, Aspergillus spores are 2. Examples of care areas where HEPA filters are used include PE rooms and those operating rooms designated for orthopedic implant procedures.

A metal frame has no advantage over a properly fitted wood frame with respect to performance, but wood can compromise the air quality if it becomes and remains wet, allowing the growth of fungi and bacteria.

Hospitals are therefore advised to phase out water-damaged or spent wood-framed filter units and replace them with metal-framed HEPA filters.

Portable HEPA filters are used to a temporarily recirculate air in rooms with no general ventilation, b augment systems that cannot provide adequate airflow, and c provide increased effectiveness in airflow.

The hospital engineering department should be contacted to provide ACH information in the event that a portable HEPA filter unit is necessary to augment the existing fixed HVAC system for air cleaning.

Filter Maintenance Efficiency of the filtration system is dependent on the density of the filters, which can create a drop in pressure unless compensated by stronger and more efficient fans, thus maintaining air flow.

The pressure differential across filters is measured by use of manometers or other gauges. A pressure reading that exceeds specifications indicates the need to change the filter.

Filters also require regular inspection for other potential causes of decreased performance. Ultraviolet Germicidal Irradiation UVGI As a supplemental air-cleaning measure, UVGI is effective in reducing the transmission of airborne bacterial and viral infections in hospitals, military housing, and classrooms, but it has only a minimal inactivating effect on fungal spores.

Most commercially available UV lamps used for germicidal purposes are low-pressure mercury vapor lamps that emit radiant energy predominantly at a wave-length of In duct irradiation systems, UV lamps are placed inside ducts that remove air from rooms to disinfect the air before it is recirculated.

When properly designed, installed, and maintained, high levels of UVGI can be attained in the ducts with little or no exposure of persons in the rooms.

Because the clinical effectiveness of UV systems may vary, UVGI is not recommended for air management prior to air recirculation from airborne isolation rooms.

It is also not recommended as a substitute for HEPA filtration, local exhaust of air to the outside, or negative pressure.

Safety issues associated with the use of UVGI systems are described in other guidelines. Conditioned Air in Occupied Spaces Temperature and humidity are two essential components of conditioned air.

After outside air passes through a low- or medium-efficiency filter, the air undergoes conditioning for temperature and humidity control before it passes through high-efficiency or HEPA filtration.

Temperature HVAC systems in health-care facilities are often single-duct or dual-duct systems. The dual-duct system consists of parallel ducts, one with a cold air stream and the other with a hot air stream.

A mixing box in each room or group of rooms mixes the two air streams to achieve the desired temperature.

Temperature standards are given as either a single temperature or a range, depending on the specific health-care zone.

Humidity Four measures of humidity are used to quantify different physical properties of the mixture of water vapor and air. The most common of these is relative humidity, which is the ratio of the amount of water vapor in the air to the amount of water vapor air can hold at that temperature.

The second mechanism is by means of water vapor created from steam and added to filtered air in humidifying boxes. Reservoir-type humidifiers are not allowed in health-care facilities as per AIA guidelines and many state codes.

Ventilation The control of air pollutants e. The second most effective means of controlling indoor air pollution is through ventilation.

Ventilation rates are voluntary unless a state or local government specifies a standard in health-care licensing or health department requirements.

These standards typically apply to only the design of a facility, rather than its operation. However, because gaseous contaminants tend to accumulate as the air recirculates, a percentage of the recirculated air is exhausted to the outside and replaced by fresh outdoor air.

In hospitals, the delivery of filtered air to an occupied space is an engineered system design issue, the full discussion of which is beyond the scope of this document.

Hospitals with areas not served by central HVAC systems often use through-the-wall or fan coil air conditioning units as the sole source of room ventilation.

AIA guidelines for newly installed systems stipulate that through-the-wall fan-coil units be equipped with permanent i.

Erickson, ASHE, Non-central air-handling systems are prone to problems associated with excess condensation accumulating in drip pans and improper filter maintenance; health-care facilities should clean or replace the filters in these units on a regular basis while the patient is out of the room.

Laminar airflow ventilation systems are designed to move air in a single pass, usually through a bank of HEPA filters either along a wall or in the ceiling, in a one-way direction through a clean zone with parallel streamlines.

Laminar airflow can be directed vertically or horizontally; the unidirectional system optimizes airflow and minimizes air turbulence.

Given the high cost of installation and apparent lack of benefit, the value of laminar airflow in this setting is questionable.

Pressurization Positive and negative pressures refer to a pressure differential between two adjacent air spaces e. Air flows away from areas or rooms with positive pressure pressurized , while 19 air flows into areas with negative pressure depressurized.

AII rooms are set at negative pressure to prevent airborne microorganisms in the room from entering hallways and corridors.

PE rooms housing severely neutropenic patients are set at positive pressure to keep airborne pathogens in adjacent spaces or corridors from coming into and contaminating the airspace occupied by such high-risk patients.

Selfclosing doors are mandatory for both of these areas to help maintain the correct pressure differential. These rooms are no longer permitted in the construction of new facilities or in renovated areas of the facility, and their use in existing facilities has been discouraged because of difficulties in assuring the proper pressure differential, especially for the negative pressure setting, and because of the potential for error associated with switching the pressure differentials for the room.

Continued use of existing variable pressure rooms depends on a partnership between engineering and infection control. Both positive- and negative-pressure rooms should be maintained according to specific engineering specifications Table 6.

Table 6. Table adapted from and used with permission of the publisher of reference 35 Lippincott Williams and Wilkins.

Health-care professionals e. The AIA guidelines require a certain number of AII rooms as a minimum, and it is important to refer to the edition under which the building was built for appropriate guidance.

Sealing the windows in PE areas helps minimize the risk of airborne contamination from the outside. One outbreak of aspergillosis among immunosuppressed patients in a hospital was attributed in part to an open window in the unit during a time when both construction and a fire happened nearby; sealing the window prevented further entry of fungal spores into the unit from the outside air.

Only limited information is available from formal 20 studies on the infection-control implications of a complete air-handling system failure or shutdown for maintenance.

Most experience has been derived from infectious disease outbreaks and adverse outcomes among high-risk patients when HVAC systems are poorly maintained.

See Table 7 for potential ventilation hazards, consequences, and correction measures. AIA guidelines prohibit U.

Maintaining these relationships can be accomplished with special drives on the air-handling units i.

Microorganisms proliferate in environments wherever air, dust, and water are present, and air-handling systems can be ideal environments for microbial growth.

The use of hand-held, calibrated equipment that can provide a numerical reading on a daily basis is preferred for engineering purposes A.

Streifel, University of Minnesota, Preventive filter and duct maintenance e. The frequency of filter inspection and the parameters of this inspection are established by each facility to meet their unique needs.

Ductwork in older health-care facilities may have insulation on the interior surfaces that can trap contaminants.

This insulation material tends to break down over time to be discharged from the HVAC system. Additionally, a malfunction of the air-intake system can overburden the filtering system and permit aerosolization of fungal pathogens.

Keeping the intakes free from bird droppings, especially those from pigeons, helps to minimize the concentration of fungal spores entering from the outside.

Clusters of infections caused by Aspergillus spp. The dual-duct system may also create conditions of high humidity and excess moisture that favor fungal growth in drain pans as well as in fibrous insulation material that becomes damp as a result of the humid air passing over the hot stream and condensing.

If moisture is present in the HVAC system, periods of stagnation should be avoided. Bursts of organisms can be released upon system start-up, increasing the risk of airborne infection.

In one hospital, endophthalmitis caused by Acremonium kiliense infection following cataract extraction in an ambulatory surgical center was traced to aerosols derived from the humidifier water in the ventilation system.

Most health-care facilities have contingency plans in case of disruption of HVAC services. These plans include back-up power generators that maintain the ventilation system in high-risk areas e.

Alternative generators are required to engage within 10 seconds of a loss of main power. If the ventilation system is out of service, rendering indoor air stagnant, sufficient time must be allowed to clean the air and re-establish the appropriate number of ACH once the HVAC system begins to function again.

Air filters may also need to be changed, because reactivation of the system can dislodge substantial amounts of dust and create a transient burst of fungal spores.

Duct cleaning in health-care facilities has benefits in terms of system performance, but its usefulness for infection control has not been conclusively determined.

Duct cleaning typically involves using specialized tools to dislodge dirt and a high-powered vacuum cleaner to clean out debris.

The U. Exhaust return systems should be cleaned as part of routine system maintenance. Duct cleaning has not been shown to prevent any health problems, and EPA studies indicate that airborne particulate levels do not increase as a result of dirty air ducts, nor do they diminish after cleaning, presumably because much of the dirt inside air ducts adheres to duct surfaces and does not enter the conditioned space.

Construction, Renovation, Remediation, Repair, and Demolition a. All of these materials can provide microbial habitat when wet.

This is especially true for fungi growing on gypsum board. Filter bypasses 17 Rigorous air filtration requires air flow resistance.

Air stream will elude filtration if openings are present because of filter damage or poor fit. Replace water-damaged materials. Incorporate fungistatic compounds into building materials in areas at risk for moisture problems.

Test for all moisture and dry in less than 72 hours. Replace if the material cannot dry within 72 hours. Use pressure gauges to ensure that filters are performing at proper static pressure.

Make ease of installation and maintenance criteria for filter selection. Properly train maintenance personnel in HVAC concerns.

Design system with filters downstream from fans. Avoid water on filters or insulation. Improper fan setting Air must be delivered at design voume to maintain pressure balances.

Air flow in special vent rooms reverses. Ductwork disconnections Dislodged or leaky supply duct runs can spill into and leaky returns may draw from hidden areas.

Pressure balance will be interrupted, and infectious material may be disturbed and entrained into hospital air supply. Air flow impedance Debris, structural failure, or improperly adjusted dampers can block duct work and prevent designed air flow.

Open windows 96, Open windows can alter fan-induced pressure balance and allow dirty-toclean air flow.

Dirty window air conditioners 96, Dirt, moisture, and bird droppings can contaminate window air conditioners, which can then introduce infectious material into hospital rooms.

Routinely monitor air flow and pressure balances throughout critical parts of HVAC system. Minimize or avoid using rooms that switch between positive and negative pressure.

Design a ductwork system that is easy to access, maintain, and repair. Train maintenance personnel to regularly monitor air flow volumes and pressure balances throughout the system.

Test critical areas for appropriate air flow 1. Design and budget for a duct system that is easy to inspect, maintain, and repair.

Alert contractors to use caution when working around HVAC systems during the construction phase. Regularly clean exhaust grilles. Provide monitoring for special ventilation areas.

Use sealed windows. Design HVAC systems to deliver sufficient outdoor dilution ventilation. Ensure that OSHA indoor air quality standards are met.

Eliminate such devices in plans for new construction. Where they must be used, make sure that they are routinely cleaned and inspected.

Maintenance disruptions Fan shut-offs, dislodged filter cake material contaminates downstream air supply and drain pans. This may compromise air flow in special ventilation areas.

Excessive moisture in the HVAC system Chronically damp internal lining of the HVAC system, excessive condensate, and drip pans with stagnant water may result from this problem.

Duct contamination 18, Debris is released during maintenance or cleaning. Possible solutions 1. Specify appropriate filters during new construction design phase.

Make sure that HVAC fans are sized to overcome pressure demands of filter system. Inspect and test filters for proper installation. Budget for a rigorous maintenance schedule when designing a facility.

Design system for easy maintenance. Ensure communication between engineering and maintenance personnel. Institute an ongoing training program for all involved staff members.

Locate duct humidifiers upstream of the final filters. Identify a means to remove water from the system.

Monitor humidity; all duct take-offs should be downstream of the humidifiers so that moisture is absorbed completely.

Use steam humidifiers in the HVAC system. Provide point-of-use filtration in the critical areas. Design air-handling systems with insulation of the exterior of the ducts.

Do not use fibrous sound attenuators. Decontaminate or encapsulate contamination. Construction, renovation, repair, and demolition activities in health-care facilities require substantial planning and coordination to minimize the risk for airborne infection both during projects and after their completion.

Several organizations and experts have endorsed a multi-disciplinary team approach Box 4 to coordinate the various stages of construction activities e.

The number of members and disciplines represented is a function of the complexity of a project. Smaller, less complex projects and maintenance may require a minimal number of members beyond the core representation from engineering, infection control, environmental services, and the directors of the specialized departments.

Suggested members and functions of a multi-disciplinary coordination team for construction, renovation, repair, and demolition projects Members Infection-control personnel, including hospital epidemiologists Laboratory personnel Facility administrators or their designated representatives, facility managers Director of engineering Risk-management personnel Directors of specialized programs e.

Conduct a risk assessment of the project to determine potential hazards to susceptible patients. Prevent unnecessary exposures of patients, visitors, and staff to infectious agents.

Oversee all infection-control aspects of construction activities. Establish site-specific infection-control protocols for specialized areas.

Provide education about the infection-control impact of construction to staff and construction workers.

Ensure compliance with technical standards, contract provisions, and regulations. Establish a mechanism to address and correct problems quickly.

Develop contingency plans for emergency response to power failures, water supply disruptions, and fires. Provide a water-damage management plan including drying protocols for handling water intrusion from floods, leaks, and condensation.

Develop a plan for structural maintenance. Education of maintenance and construction workers, health-care staff caring for high-risk patients, and persons responsible for controlling indoor air quality heightens awareness that minimizing dust and moisture intrusion from construction sites into high-risk patient-care areas helps to maintain a safe environment.

Staff and construction workers also need to be aware of the potentially catastrophic consequences of dust and moisture intrusion when an HVAC system or water system fails during construction or repair; action plans to deal quickly with these emergencies should be developed in advance and kept on file.

Incorporation of specific standards into construction contracts may help to prevent departures from recommended practices as projects progress.

Establishing specific lines of communication is important to address problems e. Health-care facility staff should develop a mechanism to monitor worker adherence to infection-control guidelines on a daily basis in and around the construction site for the duration of the project.

Preliminary Considerations The three major topics to consider before initiating any construction or repair activity are as follows: a design and function of the new structure or area, b assessment of environmental risks for airborne disease and opportunities for prevention, and c measures to contain dust and moisture during construction or repairs.

A checklist of design and function considerations can help to ensure that a planned structure or area can be easily serviced and maintained for environmental infection control Box 5.

Construction design and function considerations for environmental infection control Location of sinks and dispensers for handwashing products and hand hygiene products Types of faucets e.

Outdoor demolition and construction require actions to keep dust and moisture out of the facility e. Containment of dust and moisture generated from construction inside a facility requires barrier structures either pre-fabricated or constructed of more durable materials as needed and engineering controls to clean the air in and around the construction or repair site.

Infection-Control Risk Assessment An infection-control risk assessment ICRA conducted before initiating repairs, demolition, construction, or renovation activities can identify potential exposures of susceptible patients to dust and moisture and determine the need for dust and moisture containment measures.

This assessment centers on the type and extent of the construction or repairs in the work area but may also need to include adjacent patient-care areas, supply storage, and areas on levels above and below the proposed project.

An example of designing an ICRA as a matrix, the policy for performing an ICRA and implementing its results, and a sample permit form that streamlines the communication process are available.

Pressure readings in the affected building including 12 of 25 HSCT-patient rooms ranged from 0. Unfiltered outdoor air flowed into the building through doors and windows, exposing patients in the HSCT unit to fungal spores.

The type of barrier systems necessary for the scope of the project must be defined. Advance assessment of high-risk locations and planning for the possible transport of patients to other departments can minimize delays and waiting time in hallways.

Previous guidance on this issue has been inconsistent. Although health-care workers who would be using the N95 respirator for personal respiratory protect must be fit-tested, there is no indication that either patients or visitors should undergo fit-testing.

Surveillance activities should augment preventive strategies during construction projects. Air Sampling Air sampling in health-care facilities may be conducted both during periods of construction and on a periodic basis to determine indoor air quality, efficacy of dust-control measures, or air-handling system performance via parametric monitoring.

A periodic assessment of the system e. Particulate sampling i. Particle size is reported in terms of the mass median aerodynamic diameter MMAD , whereas count median aerodynamic diameter CMAD is useful with respect to particle concentrations.

Particle counts in a given air space within the health-care facility should be evaluated against counts obtained in a comparison area.

Particle counts indoors are commonly compared with the particulate levels of the outdoor air. This type of monitoring is helpful when performed at various times and barrier perimeter locations during the project.

Application of ACGIH guidance to health-care settings has not been standardized, but particulate counts in health-care facilities are likely to be well below this threshold value and approaching clean-room standards in certain care areas e.

The anemometer measures air flow velocity, which can be used to determine sample volumes. Particulate sampling usually does not require microbiology laboratory services for the reporting of results.

Microbiologic sampling of air in health-care facilities remains controversial because of currently unresolved technical limitations and the need for substantial laboratory support Box 6.

The most significant technical limitation of air sampling for airborne fungal agents is the lack of standards linking fungal spore levels with infection rates.

Microbiologic sampling for fungal spores performed as part of various airborne disease outbreak 28 investigations has also been problematic.

Therefore, it may be prudent for the clinical laboratory to save Aspergillus spp. Box 6. Sedimentation methods using settle plates and volumetric sampling methods using solid impactors are commonly employed when sampling air for bacteria and fungi.

Settle plates have been used by numerous investigators to detect airborne bacteria or to measure air quality during medical procedures e.

Therefore, they are considered impractical for general use. Air sampling in health-care facilities, whether used to monitor air quality during construction, to verify filter efficiency, or to commission new space prior to occupancy, requires careful notation of the circumstances of sampling.

Most air sampling is performed under undisturbed conditions. However, when the air is sampled during or after human activity e.

Comparing microbiologic sampling results from a target area e. A comparison of microbial species densities in outdoor air versus indoor air has been used to help pinpoint fungal spore bursts.

Fungal spore densities in outdoor air are variable, although the degree of variation with the seasons appears to be more dramatic in the United States than in Europe.

Particulate sampling is used as part of a battery of tests to determine if a new HVAC system is performing to specifications for filtration and the proper number of ACH.

If performed, sampling should be limited to determining the density of fungal spores per unit volume of air space. High numbers of spores may indicate contamination of air-handling system components prior to installation or a system deficiency when culture results are compared with known filter efficiencies and rates of air exchange.

External Demolition and Construction External demolition, planned building implosions, and dirt excavation generate considerable dust and debris that can contain airborne microorganisms.

Infection-control risk assessment teams, particularly those in facilities located in urban renewal areas, would benefit by developing risk management strategies for external demolition and construction as a standing policy.

In light of the events of 11 September , it may be necessary for the team to identify those dust exclusion measures that can be implemented rapidly in response to emergency situations Table 8.

Issues to be reviewed prior to demolition include a proximity of the air intake system to the work site, b adequacy of window seals and door seals, c proximity of areas frequented by immunocompromised patients, and d location of the underground utilities D.

Strategies to reduce dust and moisture intrusion during external demolition and construction Item Recommendation Demolition site Shroud the site if possible to reduce environmental contamination.

Prior to placing dust-generating equipment, evaluate the location to ensure that dust produced by the equipment will not enter the building through open doorways or windows, or through ventilation air intakes.

Locate this storage away from the facility and ventilation air intakes. Seal off affected intakes, if possible, or move if funds permit. Consult with the facility engineer about pressure differentials and air recirculation options; keep facility air pressure positive to outside air.

Ensure that filters are properly installed; change roughing filters frequently to prevent dust build-up on high-efficiency filters.

Seal and caulk to prevent entry of airborne fungal spores. Keep closed as much as possible; do not prop open; seal and caulk unused doors i.

Note location relative to construction area to prevent intrusion of dust into water systems. Provide methods e.

Close off entry ways as needed to minimize dust intrusion. Reroute if possible, or arrange for frequent street cleaning.

Encourage reporting of hazardous or unsafe incidents associated with construction. Minimizing the entry of outside dust into the HVAC system is crucial in reducing the risk for airborne contaminants.

Facility engineers should be consulted about the potential impact of shutting down the system or increasing the filtration. Selected air handlers, especially those located close to excavation sites, may have to be shut off temporarily to keep from overloading the system with dust and debris.

Care is needed to avoid significant facility-wide reductions in pressure differentials that may cause the building to become negatively pressured relative to the outside.

To prevent excessive particulate overload and subsequent reductions in effectiveness of intake air systems that cannot be shut off temporarily, air filters must be inspected frequently for proper installation and function.

Excessive dust 31 penetration can be avoided if recirculated air is maximally utilized while outdoor air intakes are shut down.

Scheduling demolition and excavation during the winter, when Aspergillus spp. To decrease the amount of aerosols from excavation and demolition projects, nearby windows, especially in areas housing immunocompromised patients, can be sealed and window and door frames caulked or weather-stripped to prevent dust intrusion.

Diverting pedestrian traffic away from the construction sites decreases the amount of dust tracked back into the health-care facility and minimizes exposure of high-risk patients to environmental pathogens.

Additionally, closing entrances near construction or demolition sites might be beneficial; if this is not practical, creating an air lock i.

Internal Demolition, Construction, Renovations, and Repairs The focus of a properly implemented infection-control program during interior construction and repairs is containment of dust and moisture.

This objective is achieved by a educating construction workers about the importance of control measures; b preparing the site; c notifying and issuing advisories for staff, patients, and visitors; d moving staff and patients and relocating patients as needed; e issuing standards of practice and precautions during activities and maintenance; f monitoring for adherence to control measures during construction and providing prompt feedback about lapses in control; g monitoring HVAC performance; h implementing daily clean-up, terminal cleaning and removal of debris upon completion; and i ensuring the integrity of the water system during and after construction.

These activities should be coordinated with engineering staff and infection-control professionals. Physical barriers capable of containing smoke and dust will confine dispersed fungal spores to the construction zone.

Short-term projects that result in minimal dust dispersion e. If the project is extensive but short-term, dust-abatement, fire-resistant plastic curtains e.

These should be completely airtight and sealed from ceiling to floor with overlapping curtains;, , holes, tears, or other perforations should be repaired promptly with tape.

A portable, industrial-grade HEPA filter unit on continuous operation is needed within the contained area, with the filtered air exhausted to the outside of the work zone.

Patients should not remain in the room when dust-generating activities are performed. Tools to assist the decision-making process regarding selection of barriers based on an ICRA approach are available.

These barrier structures typically consist of rigid, noncombustible walls constructed from sheet rock, drywall, plywood, or plaster board and covered with sheet plastic e.

See Box 7 for a list of the various construction and repair activities that require the use of some type of barrier.

Dust and moisture abatement and control rely primarily on the impermeable barrier containment approach; as construction continues, numerous opportunities can lead to dispersion of dust to other areas of the health-care facility.

Infection-control measures that augment the use of barrier containment should be undertaken Table 9. Dust-control measures for clinical laboratories are an essential part of the infection-control strategy during hospital construction or renovation.

Use of plastic or solid barriers may be needed if the ICRA determines that air flow from construction areas may introduce airborne contaminants into the laboratory space.

In one facility, pseudofungemia clusters attributed to Aspergillus spp. In addition, an outbreak of pseudobacteremia caused by Bacillus spp.

Table 9. Educate staff and construction workers. Issue hazard and warning notices. Relocate high-risk patients as needed, especially if the construction is in or adjacent to a PE area.

Establish alternative traffic patterns for staff, patients, visitors, and construction workers. Steps for implementation 1. Use a multi-disciplinary team approach to incorporate infection control into the project.

Conduct the risk assessment and a preliminary walk-through with project managers and staff. Educate staff and construction workers about the importance of adhering to infection-control measures during the project.

Provide educational materials in the language of the workers. Include language in the construction contract requiring construction workers and subcontractors to participate in infection-control training.

Post signs to identify construction areas and potential hazards. Mark detours requiring pedestrians to avoid the work area. Identify target patient populations for relocation based on the risk assessment.

Arrange for the transfer in advance to avoid delays. At-risk patients should wear protective respiratory equipment e. Determine appropriate alternate routes from the risk assessment.

Designate areas e. Do not transport patients on the same elevator with construction materials and debris. Establish proper ventilation.

Control solid debris. Control water damage. Control dust in air and on surfaces. Use prefabricated plastic units or plastic sheeting for short-term projects that will generate minimal dust.

Use durable rigid barriers for ongoing, long-term projects. Shut off return air vents in the construction zone, if possible, and seal around grilles.

Exhaust air and dust to the outside, if possible. When vibration-related work is being done that may dislodge dust in the ventilation system or when modifications are made to ductwork serving occupied spaces, install filters on the supply air grilles temporarily.

Set pressure differentials so that the contained work area is under negative pressure. Use air flow monitoring devices to verify the direction of the air pattern.

Keep windows closed, if possible. When replacing filters, place the old filter in a bag prior to transport and dispose as a routine solid waste.

Clean the construction zone daily or more often as needed. Designate a removal route for small quantities of solid debris.

Mist debris and cover disposal carts before transport i. Designate an elevator for construction crew use. Use window chutes and negative pressure equipment for removal of larger pieces of debris while maintaining pressure differentials in the construction zone.

Schedule debris removal to periods when patient exposures to dust is minimal. Make provisions for dry storage of building materials.

Do not install wet, porous building materials i. He publicly criticized insulting depictions of the Catholic Church in popular culture and the media.

He thought that the pope's experiences during World War II had been distorted and his personality misrepresented. On January 11, , Groeschel was struck by an automobile while crossing a street in Orlando, Florida.

He "suffered numerous broken bones and intracranial bleeding", [12] and over a four-hour period, he had no blood pressure, heartbeat or pulse for about 20 minutes.

Although the accident left him with limited use of his right arm and difficulty in walking, he was back preaching and giving retreats by the end of and he continued to keep a full schedule.

I lived. They said I would never think. I think. They said I would never walk. I walked. They said I would never dance, but I never danced anyway.

In Groeschel had heart problems that were addressed by bypass surgery. In Groeschel, then age 75, suffered a minor stroke overnight March 20— The stroke caused temporary cognitive and speech difficulties that were noticeable in his March 29 appearance as the host of EWTN's Sunday Night Live With Father Benedict Groeschel , where he made the condition public.

Since Groeschel served as the director of spiritual development for the Archdiocese of New York. It was in this capacity as a "defender of the priesthood" that he was drawn into the sexual abuse scandals that came to light in the early s.

In with large numbers of public allegations arising accusing priests of sexual abuse against minors, Groeschel caused some controversy during a sermon at a Yonkers church.

He described the news reporting on the matter as a "media persecution" against Catholicism intended "to destroy whatever public influence the church might have.

Groeschel also made controversial comments in a interview published by the National Catholic Register on August 27 related to the sexual abuse of children by priests: "Suppose you have a man having a nervous breakdown, and a youngster comes after him.

A lot of the cases, the youngster — 14, 16, 18 — is the seducer. I apologize for my comments. I did not intend to blame the victim.

A priest or anyone else who abuses a minor is always wrong and is always responsible. My mind and my way of expressing myself are not as clear as they used to be.

I have spent my life trying to help others the best that I could. I deeply regret any harm I have caused to anyone.

The Franciscan Friars of the Renewal organization also apologized for Groeschel's remarks, noting that they were out of character for him and stemmed from infirmities due to his car accident and a recent stroke.

Due to declining health, Groeschel had moved into St. He had an ongoing medical condition [3] that was grave enough that preparations to memorialize his life, including a Facebook tribute, were begun on September 9, , by members of his religious order.

Groeschel who is up for beatification". On the day of his death Groeschel met with Michael Mencer who as a child had his juvenile macular degeneration reversed, which he and his family accredited to the intercession of Sister Miriam Teresa Demjanovich , S.

This event was accepted by the Vatican as a miracle that qualified Demjanovich to be beatified—this was set to be declared at a Mass the next day at the Cathedral Basilica of the Sacred Heart in Newark the first such beatification Mass to be held in the U.

Mencer had the relic of Demjanovich a strand of her hair that he had carried with him when he felt his vision problems lift and loaned it to Groeschel who blessed himself with it.

Shawn Conrad O'Connor, C. After the prayer O'Connor noticed that Groeschel was unresponsive and he could not find his pulse.

After a few times asking for a response O'Connor noticed his mouth and eyes move, and felt that Groeschel was either asleep or in a "little trance" that he had been going into lately.

O'Connor then laid down. A few minutes later a nurse came in and determined that Groeschel had died.

O'Connor stated that Groeschel's last conscious action had been to pray the rosary and held that it was "a beautiful way to go.

O'Connor noted that due to illness and pain Groeschel "for the last two years and especially the last month It seemed like he was doing his Purgatory right there in front of you Members of his order held the timing of his death was providential as that night was not only the vigil before a woman from his hometown was to be beatified, but also because it fell on the vigil of the Feast of St.

Francis of Assisi their founder according to the Catholic liturgical calendar. On the memorial page set up by members of his order, Groeschel's quote concerning his attitude about his death was given, "Saint Vincent de Paul said: 'If you love the poor, your life will be filled with sunlight, and you will not be frightened at the hour of death.

Groeschel's remains were placed in a simple pine casket in accord with the rule of his community [40] and entombed in the crypt of the Most Blessed Sacrament Friary on October 12, following a funeral Mass at the Basilica Cathedral of the Sacred Heart in Newark, New Jersey.

Groeschel made many audio recordings. Among them are two rosary recordings with the singer-songwriter Simonetta that have been on Catholic radio for more than a decade:.

From Wikipedia, the free encyclopedia. The Very Reverend. Benedict Groeschel. The New York Times. National Catholic Register.

Our Sunday Visitor Publishing Division. Our Sunday Visitor. First Things. USA Today. Retrieved September 2, Francis House". Retrieved April 15, Archived from the original on January 28, Archived from the original on August 20, Benedict Groeschel - author, retreat master and preacher - dies".

National Catholic Reporter.

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