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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority as integrated effective July 1, 2015, including the legacy operations and staff of UWHC
Policy Title: Infection Control Precautions During Construction and Renovation
Policy Number: 13.16
Effective Date: January 1, 2016
Chapter: Infection Control
To minimize the risk of construction and renovation related healthcare-associated infections, most notably
those caused by airborne filamentous fungi.
A. The Facilities and Engineering Services (FES) and Facilities Planning, Design and Construction
(PDC) Departments will maintain representation on the hospital Infection Control Committee,
and will provide a report of upcoming and current construction and renovation projects in all UW
Health locations as a standing agenda item at these monthly meetings.
B. In order to allow detailed consideration of patient risk and to ensure oversight of design elements
which impact regulatory compliance and the control of infection (e.g., enhanced air filtration,
sufficient number and type of special ventilation rooms, clean and soiled item separation, hand
hygiene, etc.), representation of an Infection Control Practitioner and/or the Hospital
Epidemiologist will be included on planning groups for:
1. New construction of patient care areas.
2. Extensive renovations of existing patient care areas, as detailed under Construction
Activity Risk Level D on the Pre-Construction Infection Control Risk Assessment Form.
3. Planned interruptions of air handling units or potable water affecting patient care areas,
patient procedure areas, reprocessing/sterilization areas, and any other area which may
impact patients directly or indirectly.
4. Projects which entail substantial excavation of earth contiguous to the hospital (e.g.,
excavating large areas for new building construction).
C. Before beginning any renovation or construction project within UW Health inpatient or
ambulatory facilities, an authorized FES or PDC staff member (defined in C.1., below) will
complete a Pre-construction Infection Control Risk Assessment (ICRA) form.
1. For purposes of this policy, ‘authorized FES or PDC staff’ will include only: Facilities
and Engineering Services Director, Managers, Supervisors, Construction Coordinators,
Construction Managers, zone mechanics and PDC Project Managers.
2. If the Pre-construction ICRA form indicates that level II precautions are necessary, work
may not proceed until the manager of the affected inpatient unit or manager of the
ambulatory clinic signs the appropriate section of the Pre-construction Authorization
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3. If the Pre-construction ICRA form indicates that level III or IV precautions are necessary,
work may not proceed until the manager of the inpatient unit or the manager of the
ambulatory clinic, an authorized FES or PDC staff member, and an Infection Control
Practitioner each sign the appropriate authorization section of the Pre-construction
4. Due to the wide geographic distribution of outlying ambulatory clinics, all ICRAs for
these locations, regardless of level I-IV, will be forwarded by the PDC Facilities Projects
Manager assigned to ambulatory locations to an Infection Control Practitioner assigned to
ambulatory location oversight for review.
D. FES or PDC or their designee staff will be responsible for subsequent daily checks and
assessment of site containment, using the Daily Worksite Checklist.
1. Deficits in containment noted in completing the Daily Worksite Checklist which cannot
be readily remediated by FES or PDC staff will be reported to the Infection Control
Practitioner (ICP) on call through the hospital paging operator (262-2122) or by paging
#2570 for worksites within University Hospital, American Family Children’s Hospital or
The American Center, or pager #7826 for ambulatory locations.
2. Work at the site will be halted until the ICP can coordinate with FES or PDC staff to
ensure proper containment.
E. Contracted construction personnel will be held to the same level of accountability as UW Health
employees with regard to the uniform application of this policy to protect vulnerable patients
during construction/renovation. Failure of contracted personnel to comply with these precautions
will be grounds for immediate removal from the job site.
1. This UW Health policy, along with Safety/ Infection Control guidelines for Contractors,
will be provided in advance of contractual agreements with outside companies to ensure
that they understand the precautions necessary to protect vulnerable patients. Acceptance
of a contract to work in UW Health will be evidence that the contracting company
accepts the stipulations of this policy and agrees to comply with them.
F. Infection Control personnel will provide relevant education about infectious risks associated with
construction activities to FES and PDC staff, as well as to contracted staff as warranted.
G. The ICRA makes up one of three parts of pre-construction documentation. Please review the
Interim Life Safety Program (ILSM) Administrative Policy 12.45, ILSM decision tree and the
Pre-Construction Risk Assessment (PCRA) to complete all required documentation for the
III. FORMS USED
Pre-Construction Infection Control Risk Assessment Form
Pre-Construction Authorization Form
Daily Worksite Checklist
A. Prior to beginning construction/renovation activities, an authorized FES or PDC staff member
will review the proposed activities and complete a Pre-construction Infection Control Risk
Assessment (ICRA) form. This form applies a grid which uses consistent definitions of patient
risk levels and construction activity risk levels to determine the level of Infection Control
Precautions warranted for the particular project.
B. If a project includes multiple locations, one ICRA may be filled out (listing all locations of work)
for each IC level.
C. After the ICRA has been completed and the Infection Control Precautions Level required to
proceed has been identified, the authorized FES or PDC staff member will then apply the
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precautions which are associated with the identified level to the project. These Infection Control
Precaution Level-specific precautions are delineated on the Pre-construction Authorization Form.
1. Level I Infection Control Precautions pertain to inspections and very minor repair work
in low to moderate risk environments. Projects requiring only level I Infection Control
Precautions can proceed without further authorization.
2. Level II Infection Control precautions require that the manager of the affected inpatient
unit, manager of the affected non-patient care area or manager of the affected ambulatory
clinic location where work is to be performed sign off on the level II section of Pre-
construction Authorization Form, documenting that he/she has been notified of the
pending work, and that no vulnerable patients need to be relocated from the unit during
a. Work is not to begin until the manager of the affected inpatient unit, manager of
the affected non-patient care area or manager of the affected ambulatory clinic
location signs off on the Pre-construction Authorization Form. If the manager is
unsure of the need to relocate patients, or is otherwise unsure about infectious
risks to patients, the manager will decline to sign the form and the Infection
Control Practitioner (ICP) on call will be consulted.
3. Level III and IV Infection Control Precautions require the signatures of the manager of
the affected inpatient unit, manager of the affected non-patient care area or manager of
the affected ambulatory clinic location, the authorized FES or PDC staff member who
completed the risk assessment, and an ICP at the appropriate section of the Pre-
construction Authorization Form prior to the beginning of service work.
a. Level III ICRAs for planned projects must be submitted to Infection Control at
least 48 hours before the project start date and must include a detailed description
of location and work planned.
b. Level IV ICRAs for planned projects must be submitted to Infection Control at
least 7 days before the project start date and must include a detailed description
of location and work planned.
c. The signature of manager of the affected inpatient unit, manager of the affected
non-patient care area or manager of the affected ambulatory clinic location
documents that he/she has been notified of the pending work and that no
vulnerable patients need to be relocated from the unit during the service work.
d. The signature of the authorized FES or PDC staff member documents that he/she
has completed the ICRA to determine the level of precautions required, and that
these have been put into place.
e. The signature of the ICP documents that he/she has reviewed the ICRA and
agrees with the level of precautions required (e.g., dust barriers, evacuating fans,
f. The ICP will have the prerogative to implement specific additional control
measures, or to increase or decrease the overall Infection Control Precaution
Level, based on situational patient risk or containment issues.
g. For level III and level IV work, the Project Manager or authorized FES or PDC
staff member will complete a preliminary worksite evaluation to ensure that all
control measures are in place prior to work beginning.
h. Once all appropriate signatures are obtained the authorized FES or PDC staff
member should review these requirements with the individual(s) responsible for
completing the work and the ICRA shall be posted at the worksite.
D. If, during the execution of any project, it becomes evident that more extensive demolition or
renovation activities will be necessary than were originally planned for, the authorized FES or
PDC staff member will complete an updated Pre-construction ICRA form and obtain necessary
authorization, as described in IV. A - C., before the additional steps or phases can begin.
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E. A Daily Worksite Checklist will be maintained for each project requiring level III or level IV
Infection Control Precautions. The checklist requires daily inspection of containment parameters
at the specific worksite.
1. It will be the responsibility of the authorized FES or PDC staff member overseeing the
particular project to ensure that the daily worksite checklist is accurately and consistently
a. For projects being completed by contracted staff, the on-site contractor
supervisor will have responsibility for completing the checklist and the FES or
PDC project manager assigned to the project will have oversight as described in
2. Completed checklists will be retained in the project history documentation file by the
Department (FES or PDC) which performed or had oversight of the work for at least six
months after completion of the project to accommodate data review and documentation
of control measures.
3. If a deficit in a checklist parameter is found, it must be remediated immediately and this
deficit and remediation will be noted on the Checklist.
4. If a deficit in a checklist parameter is found which cannot be readily remediated, the
authorized FES or PDC staff member responsible for the worksite must be immediately
5. If the authorized FES or PDC staff member cannot remediate the deficit, or there will be
a delay in the remediation, work at the site must be immediately halted and the ICP on
call must be notified via the paging operator (262-2122) or pager 2570 for worksites
within University Hospital, American Family Children’s Hospital or The American
Center, or pager 7826 for ambulatory locations.
6. The ICP will work with the authorized FES or PDC staff member to remediate the
containment deficit and work will not resume until cleared by the Infection Control
F. When scheduled or non-emergent interruption of utilities such as potable water or air handling
units is to occur, the manager of the affected unit(s) or ambulatory location and the ICP on call
must be notified as soon as possible and at least 72 hours in advance, so that an assessment may
be made regarding potential impact to vulnerable patients.
1. If it appears that such utility interruption may pose a risk to patients, steps to remove or
mitigate this risk will be put in place prior to utility interruption.
2. If there is insufficient time to establish protective measures against infectious risks, the
utility interruption will be delayed until the ICP is able to ensure that reasonable
protections are in place.
G. Unanticipated interruption of utilities such as potable water or air handling units, as well as
unanticipated water leaks which are of sufficient volume to soak porous materials (e.g., carpets,
drywall, ceiling tiles) must be reported immediately to the manager of the affected inpatient or
ambulatory unit(s). The ICP on-call must be notified immediately by paging 2570 for locations
within University Hospital, American Family Children’s Hospital or The American Center, or
pager 7826 for ambulatory locations in the case of an air handling failure or failure of negative or
positive pressure isolation room or sewage backup so that an assessment of patient risk can be
performed and emergent control steps implemented. For other failures such as temperature or
humidity failure or clean water leak, infection control may be notified electronically at
email@example.com unless immediate action by the ICP is needed.
H. The authorized FES or PDC staff member will have responsibility for reviewing proposed
contracted work with the contract company site supervisor, and for completing the ICRA Form
and obtaining appropriate authorization signatures on the Infection Control Precautions
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1. The contract company site supervisor will be responsible for ensuring that the daily
worksite checklist is accurately and consistently completed for projects requiring level III
or IV Infection Control Precautions.
2. FES or PDC staff will have the authority to review the Daily Worksite Checklists
maintained by contract personnel at any time to ensure that proper worksite containment
is being maintained.
3. At the conclusion of the contracted project, the contract company site supervisor will
provide the Daily Worksite Checklists to the Department (FES or PDC) which had
oversight of the work for retention as described in IV. E.
V. CROSS REFERENCE
UW Health Clinical Policy 13.06-Precautions for Immunocompromised Patients (Neutropenia
Administrative Policy 12.45-Interim Life Safety Program.
Centers for Disease Control and Prevention. Guidelines for Environmental Infection Control in Health-
Care Facilities, 2003. Recommendations of CDC and the Healthcare Infection Control Practices Advisory
Committee (HICPAC). http://www.cdc.gov/ncidod/hip/enviro/guide.htm
Sr. Administrative Sponsor: SVP, Patient Care Services & CNO
Author: Infection Control Practitioner
Reviewer: Hospital Epidemiologist
Approval Committee(s): Infection Control Committee; UW Health Administrative Policy and Procedure
President, University of Wisconsin Hospitals
Chief of Clinical Operations
Previous revision: 012013
Next revision: 012019