Mold becomes a high priority for hospitals

Accreditation Connection, February 22, 2004

Mold presents a difficult and expensive dilemma for hospitals. Not only does it cause structural damage to facilities, it is also a direct cause of dangerous health care-associated infections (HAIs).

Thanks to prodding from accreditors and agencies such as the JCAHO and the CDC, many hospitals are placing increased importance on preconstruction risk assessments and maintaining constant vigilance to keep mold from growing out of control. However, there's still a long way to go, experts say.

The CDC estimates that HAIs affect 2 million patients annually, with more than 90,000 fatalities per year as a result. These statistics have led to strengthened IC guidelines and standards from the CDC, the JCAHO, the Association for Professionals in Infection Control and Epidemiology, and the American Institute of Architects.

Age-old problem
How much of a role mold plays in HAIs is still a matter of debate, but there's no question that mold has been a problem for centuries.

"It's more of a problem [now] only because people are noticing it more," says Wayne Hansen, PE, REA, CEM, director of engineering for the Mintie Corporation in Los Angeles.

Indeed, a passage in the book of Leviticus in the Bible, written more than 3,000 years ago, discusses how to deal with mold, says Jeff Heisler, senior project manager for AMEC Earth and Environmental in Louisville, KY.

"We've literally been dealing with mold for several thousand years," Heisler notes. "The same technology was used then as today. Scrape it off, see if it comes back." If the mold returns, then you need to take more extensive measures to deal with it.

Some of the most common forms of mold are aspergillus, penicillium, cladosporium, alternaria, and mucor. In those with mold allergies, reactions to mold can range from nasal stuffiness and wheezing to more serious symptoms such as fever and shortness of breath. People exposed to large amounts of mold may also experience severe reactions.

There is real danger in ignoring the possibility of mold in a hospital. "Mold to a healthy person is not a big deal," says Heisler. "But to an immunocompromised patient, mold is a much more pressing issue."

Mark Hodgson, director of indoor air quality for Clayton Group Services in Edison, NJ, says there are a few crucial reasons that mold is a bigger infectious disease threat than it used to be.

"We are keeping people alive today who 20 years ago would not have been alive," he says, which means there are more immunocompromised people in hospitals. These patients are extremely susceptible to HAIs.

In addition, physicians perform newer, riskier organ transplants and procedures every day in hospitals. "Transplant recipients have their immune systems deliberately switched off," Hodgson says.

Infections also occur when hospitals put patients in the wrong kinds of wards, and when maintenance or renovation activities take place next to hospital wards, Hodgson adds. Any time a hospital begins maintenance, renovation, or demolition work, it must take precautions to keep mold spores from spreading, he says.

"Just disturbing settled dust can be sufficient to cause an outbreak," says Hodgson.

Greater awareness of the problem
Hospitals are increasingly aware of the pitfalls of having mold in a facility, but that doesn't always translate into action.

"Across the board, there is a greater awareness [of the dangers of mold]," Hansen says. "Liability factors into it. The [chief executive officer] may say, 'I don't have $50,000 to do a risk assessment,' but the risk manager says it'll cost more to deal with the problems after the fact."

Larger hospitals are more adept at handling the problem, Heisler adds.

"The bigger the hospital, the greater the understanding of risk, and the better they are in dealing with it," Heisler says. "The smaller the hospital, the greater the risk."

The key is performing an IC risk assessment (ICRA) to determine the extent of the mold problem before beginning construction or renovation projects, adds Heisler.

"Everybody's figuring out how to do these ICRAs," he says. "Their understanding that mold is out there and ubiquitous is not what it should be. In reality, it's there when you open the doors to the facility. The key is managing it."

Sources of mold include wet drywall, leaky steam pipes, and condensation from gas lines, Heisler says. Essentially, mold is everywhere.
"Mold is prevalent in any building," Hansen says. "It's prevalent in any environment."

As long as mold is sealed away, it's no danger to a facility's patients, Hansen says. However, a hospital has a lot of pipes, and if there's a leak and the facility has to open a wall to repair it, that can release mold into the hospital environment, he adds.

Heisler says facilities must take a holistic approach to mold, incorporating contractors, engineers, and IC professionals (ICPs). See the article below for more on how ICPs should handle mold issues.

From the Pentagon to courthouses
The highest profile mold problem in recent memory could be at the Pentagon, where Heisler's firm was called in after the September 11, 2001, terrorist attack on the building.

Terrorists crashed a passenger plane into part of the Pentagon that was under renovation. As a result, the Pentagon lost power to the building, had excess water from emergency crews, and had a lot of carbon in the air caused by the building burning. All of these led to an incredible amount of mold, Heisler says.

"Mold grew by inches per day," recalls Heisler, "but we reacted quickly and were able to limit that. We saved [the Pentagon] literally millions."

Hansen cites the example of a Florida courthouse in Orange County, which in 2003 wrapped up 14 years' worth of lawsuits over mold in the building. "It was a $3 million building and it cost $50 million in lawsuits and repairs because of mold," he says.

"Contractors are getting smarter," says Hansen. "They're all looking at this as the new cost of doing business. They can use it as a positive with clients."

Education changes attitudes
Hansen says the work he does at hospitals has as much to do with education as mold remediation."It's a new paradigm of changing attitudes," he says. "It's a huge educational effort that has to take place, not only for contractors and vendors, but for hospital staff."

It takes an average of six to eight weeks of education and vigilance in a construction project until awareness of IC becomes a habit with contractors and hospital staff, says Hansen. "We're all creatures of habit," he adds. "I catch myself doing things because it's quicker when I know better. The hard part is education and changing people's habits."

Tips for ICPs to consider when dealing with mold

Infection control professionals (ICPs) play an important role in preventing the spread of mold in hospitals. Jeff Heisler, senior project manager for AMEC Earth and Environmental in Louisville, KY, offers the following tips for ICPs:

  • Any time you have any type of construction in your facility, understand what's happening and where it's happening. Do an IC risk assessment. "The greatest source of problems is construction," he says.
  • Pay attention to indoor air quality. ICPs need to become intimately aware of renovation programs in their facilities. "The biggest tendency we see in IC nurses is they pay attention to the clinical side of things, but they don't shift over to the facilities side," Heisler notes. "The same air handler that feeds the lobby also feeds the wards."
  • Don't underestimate water. Do an audit of the facility and look for potential areas of intrusion, such as condensate lines. At one facility, Heisler saw a water sprinkler hitting the brick face of a building. The hospital ended up having mold and rot drywall in four or five patient rooms because of an improperly aligned water sprinkler. Look at the roofing system, landscaping, condensate lines, plumbing lines, and laboratory lines for water infiltration.
  • Ensure the performance of regular maintenance on the facility, such as changing air filters.

IC and ventilation requirements for PE rooms

A. -Minimize exposures of severely immunocompromised patients (e.g., solid-organ transplant patients or allogenic neutropenic patients) to activities that might cause aerosolization of fungal spores (e.g., vacuuming or disruption of ceiling tiles)

B. -Minimize the length of time that immunocompromised patients in protective environments (PE) are outside their rooms for diagnostic procedures and other activities

C. -Provide respiratory protection for severely immunocompromised patients when they must leave PE for diagnostic procedures and other activities; consult the most recent revision of CDC's Guideline for Prevention of Health-Care-Associated Pneumonia for information regarding the appropriate type of respiratory protection

D. -Incorporate ventilation engineering specifications and dust-controlling processes into the planning and construction of new PE units:

1. -Install central or point-of-use high efficiency particulate air (HEPA) filters for supply (incoming) air

2. -Ensure that rooms are well-sealed by doing the following:- Properly constructing windows, doors, and intake and exhaust ports- Maintaining ceilings that are smooth and free of fissures, open joints, and crevices- Sealing walls above and below the ceiling; - Monitoring for leakage and making any nec essary repairs

3. -Ventilate the room to maintain Z 12 air changes per hour

4. -Locate air supply and exhaust grilles so that clean, filtered air enters from one side of the room, flows across the patient's bed, and exits from the opposite side of the room

5. -Maintain positive room air pressure ( Z 2.5 Pa [0.01 in water gauge]) in relation to the corridor

6. -Maintain airflow patterns and monitor these on a daily basis by using a permanently installed visual means of detecting airflow in new or renovated construction, or by using other visual methods (e.g., flutter strips or smoke tubes) in existing PE units; document the monitoring results

7. -Install self-closing devices on all room exit doors in PE rooms

E. -Do not use laminar air flow systems in newly constructed PE rooms

F. -Take measures to protect immunocompromised patients who would benefit from a PE room and who also have an airborne infectious disease (e.g., acute VZV infection or tuberculosis)

1. -Ensure that the patient's room is designed to maintain positive pressure

2. -Use an anteroom to ensure appropriate air-balance relationships and provide independent exhaust of contaminated air to the outside, or place a HEPA filter in the exhaust duct if the return air must be recirculated

3. -If an anteroom is not available, place the patient in airborne infection isolation and use portable, industrial-grade HEPA filters to enhance filtration of spores in the room

G. -Maintain backup ventilation equipment (e.g., portable units for fans or filters) for emergency provision of required ventilation for PE areas and take immediate steps to restore the fixed ventilation system

Editor's note:Excerpted from the CDC's Guidelines for Environmental Infection Control in Health-Care Facilities, 2003.  

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