Construction and Renovation Projects--Other Standards and Guidelines

Hospital Safety Center Website, July 5, 2007

[1] Introduction

In addition to OSHA standards, standards and guidelines of the following organizations apply to construction and renovation activities conducted at health care facilities:

  • The Joint Commission sets requirements for construction and renovation projects that address design and planning criteria, fire safety, patient privacy, employee training and performance, and infection control.
  • The American Institute of Architects has issued guidelines for the design and construction of health care facilities that contain information on standards for construction, ventilation, and equipping new medical facilities.
  • The CDC's Hospital Infections Program addresses infection control issues related to construction and renovation projects.
  • The NFPA has developed building construction codes that include standards for windows and doors; chimneys and vents; the fire-resistivity of floor-ceiling assemblies, walls used to form compartments and other finish materials; exterior or interior bearing walls; and other structures.
  • ANSI's building construction codes apply to ordinary building construction and contain the basic requirements for operations encountered in such work.

NIOSH Construction-Related Activities

[2] Joint Commission Standards

The Joint Commission's Comprehensive Accreditation Manual for Hospitals, The Official Handbook, includes standards applicable to health care facility construction and renovation projects.

Joint Commission Environment of Care standard EC.3.2.1 requires that when planning new construction, alteration, or renovation of facilities, organizations should use design criteria referenced by the health care community. The intent of the standard states that organizations specifically should use the American Institute of Architects' Guidelines for Design and Construction of Hospitals and Health Care Facilities, 2001 edition, applicable state rules and regulations, or similar standards or guidelines.

The standard's intent statement requires hospitals, ambulatory care, long-term care, and behavioral health care facilities to conduct a "proactive risk assessment using risk criteria to identify hazards that could potentially compromise patient care in occupied areas of the organization's buildings." This preconstruction risk assessment for demolition, construction, or renovation activities is consistent with guidelines to be published by the CDC and the AIA. The risk criteria should address any work's impact on air quality, infection control, utilities, noise, vibration, and emergency procedures. For sample checklists to help complete preconstruction surveys for indoor air quality, see Indoor Air Quality Management Preconstruction Checklist For Minor Renovation and Indoor Air Quality Management Preconstruction Checklist For Major Renovation . For infection control management , see Daily Air Quality And Infection Management Checklist.
 To help health care facilities comply with Environment of Care standards, the Joint Commission has issued Planning, Design, and Construction of Health Care Environments. The guide covers such areas as facility planning, determining project scope, working with architects and consultants, and determining and maintaining budgets and schedules.

Joint Commission standard EC.1.5.1 requires that newly constructed and existing health care facilities be designed and maintained to comply with the 2000 edition of the NFPA's Life Safety Code® (LSC) (NFPA 101-2000). Buildings for which plans were approved after January 1, 1998, will be evaluated as "new construction" under the applicable occupancy chapters of the 2000 edition of the LSC®.

Under EC.1.5.1, for every building in which patients are treated or housed overnight, a comprehensive Statement of ConditionsT (SOC) that describes the current condition of structural features of fire protection must be prepared for submission to the Joint Commission when requested.

In cases where a facility is not in compliance with NFPA 101-2000 and does not have a documented equivalency granted by the Joint Commission, a written plan for improvement is required. The plan should address all LSC® deficiencies identified in the SOC. (For more information about equivalencies, see Joint Commission Fire Prevention Standards.)

Interim life safety measures. The Joint Commission requires that organizations develop a policy for the use of ILSMs to temporarily compensate for hazards posed by NFPA LSC deficiencies or construction activities. The policy must include written criteria for evaluating such hazards to determine when and to what extent one or more ILSMs are appropriate.

ILSMs apply to all affected personnel, including construction workers, must be implemented upon project development, and must be continuously enforced through project completion, according to the Joint Commission. Interim measures must be implemented in or adjacent to all construction areas and throughout buildings with existing LSC® deficiencies. Each ILSM action must be documented through written policies and procedures, with frequency of inspection, testing, training, and monitoring and evaluation determined by the hospital. See Interim Life Safety Measures Checklist for an ILSM checklist and Interim Life Safety Measures Inspection Worksheet .

Under Joint Commission standard EC.2.5, ILSMs may include one or more of the following 11 actions:

  1. Ensure free and unobstructed exits, providing additional staff training when alternative exits are designated, and maintaining and inspecting daily escape routes to be used by construction workers in construction areas.
  2. Ensure free and unobstructed access to emergency services and for fire, police, and other emergency forces.
  3. Ensure that fire alarm, detection, and suppression systems are in good working order, providing a temporary but equivalent system, inspected and tested monthly, when any fire system is impaired. (In addition, if an approved fire alarm or automatic sprinkler system is out of service for more than four hours during any 24-hour period, the organization must notify the local fire department and institute a fire watch.)
  4. Ensure that temporary construction partitions are smoke-tight and built of noncombustible or limited combustible materials.
  5. Provide additional fire-fighting equipment and train personnel in its use.
  6. Prohibit smoking according to Joint Commission standard EC.1.1.2 throughout the organization's buildings and in and adjacent to construction areas.
  7. Develop and enforce storage, housekeeping, and debris removal practices that reduce the building's flammable and combustible fire load to the lowest feasible level.
  8. Conduct a minimum of two fire drills per shift per quarter.
  9. Increase hazard surveillance of buildings, grounds, and equipment, with special attention to excavations, construction areas, construction storage, and field offices.
  10. Train personnel to compensate for impaired structural or compartmentalization features of fire safety.
  11. Conduct organizationwide safety education programs to promote awareness of LSC® deficiencies, construction hazards, and ILSMs.

Additional Joint Commission standards applicable to construction contractors, subcontractors, and their employees include the following:

  • Patient rights and organization ethics standard RI.1.3 requires hospitals to demonstrate respect for patient needs, including confidentiality, privacy, and security.
  • Management of human resources standard HR.1 requires the hospital's leaders to define the qualifications and performance expectations for all staff positions.
  • Standard HR.3 requires the leaders to ensure that the competence of all staff members is assessed, maintained, demonstrated, and improved continually.
  • Standard HR.4 requires an orientation process that provides initial job training and information and assesses the staff's ability to fulfill specified responsibilities.
  • Surveillance, prevention, and control of infection standard IC.4 requires the hospital to take action to prevent or reduce the risk of nosocomial infections in patients, employees, and visitors.

For more information on Joint Commission standards, see Joint Commission Accreditation.

[3] AIA Guidelines

The AIA Guidelines for Design and Construction of Hospital and Health Care Facilities, 2001 edition, contains information on standards for construction, ventilation, and equipping new medical facilities. The guidelines include the following elements:

Planning and design. Continual health care facility upgrade through renovation and new construction of hospital facilities can create conditions that can be hazardous to patients. Design and planning for such projects in the health care facilities may require consultation from infection control professionals and safety personnel.

According to the AIA, facility managers should inform contractors of the following planning and design elements:

  • Involvement of infection control, safety, and risk management
  • Risk assessment of susceptible patient locations
  • The effects of shutting off power, shutting down heating, ventilation, and air conditioning systems, disruptions of ventilation and air flow, and outdoor wind patterns

Planning and design elements to be included in bid documents include

  • air flow (from patient-occupied areas to construction site)
  • instructions on building services interruption
  • communication requirements-both internal and external

Phasing. Projects involving renovation of existing buildings should include phasing to minimize disruption of existing patient services. According to the AIA, phasing is essential to ensure a safe environment in patient care areas. Phasing should include assurance for clean-to-dirty airflow, emergency procedures, criteria for interruption of protection, construction of roof surfaces, written notification of interruptions, and communication authority.

Contractors should be informed of the following phasing elements:

  • When renovation projects should be phased
  • Plans for emergencies (breached walls)
  • Written notifications of shutdowns
  • Procedures for interruption of protection
  • Control of noise and vibration
  • Maintaining air quality (at existing levels)

Commissioning. Acceptance criteria for mechanical systems should be specified, according to AIA guidelines. Crucial ventilation specifications for air balance and filtration should be verified before owner acceptance. Areas requiring special ventilation include surgical services, protective environments, airborne infection isolation rooms, laboratories, and local exhaust systems for hazardous agents. These areas should be recognized as requiring mechanical systems that ensure infection control.

Contractors and engineers should perform acceptance tests on all special ventilation systems serving

  • surgical services
  • protective environment rooms
  • airborne infection isolation rooms
  • laboratories
  • autopsy rooms
  • local exhaust systems for hazardous agents

Ventilation systems not performing up to design standards should not be accepted. Acceptance criteria should be specified and verified.

The AIA recommends that commissioning elements in contractors' bid documents should include

  • acceptance criteria
  • verification of air balance to owner
  • special considerations for surgical areas and obstetrics, airborne isolation and protective environment isolation rooms, laboratories, and hazardous agent exhaust hoods

Nonconforming conditions. The AIA notes that it is not always financially feasible to renovate the entire existing structure in accordance with the AIA guidelines. In such cases, authorities having jurisdiction may grant approval to renovate portions of the structure if facility operation and patient safety in the renovated areas are not jeopardized.

[4] CDC Infection Control Guidelines

The CDC's Hospital Infections Program addresses infection control issues related to construction and renovation projects. The CDC has issued guidelines for constructing units for high-risk patients, developing a plan to prevent exposures, and procedures to follow during construction and renovation activities.

Tuberculosis (TB). The CDC provides information regarding the use of ventilation and ultraviolet germicidal irradiation for preventing the transmission of M. tuberculosis in health care facilities.

Recommendations for engineering controls include

  • local exhaust ventilation (i.e., source control)
  • general ventilation considerations, including dilution and removal of contaminants, airflow patterns within rooms, airflow direction in facilities, negative pressure in rooms, and TB isolation rooms
  • air cleaning or disinfection, accomplished by filtration of air (e.g., through high-efficiency particulate air filters) or by ultraviolet germicidal irradiation

Ventilation systems for health care facilities should be designed, and modified when necessary, by ventilation engineers in collaboration with infection control and occupational health staff.

Recommendations for designing and operating ventilation systems have been published by the American Society of Heating, Refrigeration, and Air Conditioning Engineers; the American Institute of Architects; and the American Conference of Governmental Industrial Hygienists, Inc.

As part of the TB infection control plan, the CDC recommends that health care facility personnel should determine the number of TB isolation rooms, treatment rooms, and local exhaust devices (i.e., for cough inducing or aerosol generating procedures) that the facility needs. The locations of these rooms and devices may depend on where in the facility the recommended ventilation conditions can be achieved. Grouping isolation rooms together in one area of the facility may facilitate the care of TB patients and the installation and maintenance of optimal engineering controls, particularly ventilation (Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities).

Aspergillosis. Aspergillus spp. commonly occur in soil, water, and decaying vegetation. The fungi have been cultured from unfiltered air, ventilation systems, contaminated dust dislodged during hospital renovation and construction, horizontal surfaces, food, and ornamental plants (see box, "Airborne Particulates and Fungi During Hospital Renovation") .

Nosocomial aspergillosis has been recognized increasingly as a cause of severe illness and mortality in highly immunocompromised patients (e.g., patients undergoing chemotherapy and/or organ transplantation, including bone marrow transplantation for hematologic and other malignant neoplasms).

Airborne Particulates and Fungi During Hospital Renovation
The most important nosocomial infection due to Aspergillus spp. is pneumonia. Hospital outbreaks of pulmonary aspergillosis have occurred mainly in granulocytopenic patients, especially in bone-marrow transplant units.

Environmental disturbances due to construction and/or renovation activities in and around hospitals markedly raise the airborne Aspergillus spp. spore counts in such hospitals and have been associated with nosocomial aspergillosis. Investigations have shown the importance of construction activities and/or fungal contamination of hospital air-handling systems as major sources for outbreaks.

Specialized services in many large hospitals, in particular bone-marrow transplant services, have installed "protected environments" for the care of high-risk patients and increased their vigilance during hospital construction and routine maintenance of hospital air-filtration and ventilation systems to prevent exposing the patients to bursts of fungal spores.

The CDC recommends that when planning hospital construction and renovation activities, the facility should assess whether patients at high risk for aspergillosis are likely to be exposed to high ambient air spore counts of Aspergillus spp. from construction and renovation sites and develop a plan to prevent such exposures. The agency recommends the following precautions during construction or renovation activities:

  • Construct barriers between patient care and construction areas to prevent dust from entering patient care areas. These barriers, (e.g., plastic or drywall) should be impermeable to Aspergillus spp.
  • In construction/renovation areas inside the hospital, create and maintain negative pressure relative to that in adjacent patient care areas if there are no contraindications for such pressure differential (e.g., there are patients with infectious tuberculosis in the adjacent patient care areas).
  • Direct pedestrian traffic from construction areas away from patient care areas to limit opening and closing of doors (or other barriers) that may cause dust dispersion, entry of contaminated air, or tracking of dust into patient areas.
  • Clean newly constructed areas before allowing patients to enter the areas (Guideline for Prevention of Nosocomial Pneumonia. MMWR. 1995;44 [RR-12]).

[5] NFPA Standards

NFPA building construction codes include standards for exterior or interior bearing walls, columns, and other structures. Additional provisions address windows and doors; chimneys, fireplaces, and vents; and the fire-resistivity of floor-ceiling assemblies, walls used to form compartments, and other finish materials.

Other applicable NFPA codes include the following:

  • Fire Prevention Code® (NFPA 1)
  • National Electrical Code® (NFPA 70)
  • National Fire Alarm Code® (NFPA 72)
  • Fire Doors and Windows Code (NFPA 80)
  • Health Care Facilities Code (NFPA 99)
  • LSC (NFPA 101)
  • Fire Walls and Fire Barrier Walls Code (NFPA 221)

For laboratories, NFPA provides criteria on construction, exit details, and fire protection. For more information, see NFPA Safe Practices.

[6] ANSI Standards

The ANSI building construction code (ANSI A10.2-1944) applies to ordinary building construction and contains the basic requirements for the operations usually encountered in such work. Other applicable ANSI standards include the following:

  • Safety Requirements for Demolition (ANSI A10.6-1969)
  • Safety Requirements for Concrete Construction and Masonry Work (ANSI A10.9-1970)
  • Minimum Design Loads in Buildings and Other Structures (ANSI A58.1-1982)
  • Safety Code for Cranes, Derricks, Hoists, Jacks, and Slings (ANSI B30.2.0-1967)
  • Code for Pressure Piping (ANSI B31.1.0b-1971)
  • National Electrical Safety Code (ANSI C2- 1993)
  • Safety Level of Electromagnetic Radiation With Respect to Personnel (ANSI C95.1-1974)
  • Standards for the Measurement of Real-Ear Protection of Hearing Protectors and Physical Attenuation of Earmuffs (ANSI S3.19-1974)
  • Safety Code for Head, Eye, and Respiratory Protection (ANSI Z2.1-1959)
  • Safety in Welding and Cutting (ANSI Z49.1- 1973)
  • Safety Standard for the Non-Medical Use of X-ray and Sealed Gamma-ray Sources (ANSI Z54.1-1963)
  • Practices for Respiratory Protection (ANSI Z88.2-1991)
  • Safe Use of Lasers (ANSI Z136.1-1993)
  • Emergency Eyewash and Shower Equipment Standards (ANSI Z358.1-1981)

Other ANSI standards may apply during specific phases of construction and renovation projects.