ICRA Drawings: Your Map to an ICRA Plan that Works

An ICRA plan is required by the Joint Commission for any hospital project.

We all know about the importance of Infection Control Risk Assessments (ICRA), which are a requirement of the Joint Commission’s Accreditation Process for hospitals.  According to Chapter 5, Section 5.1 of the Guide to Prevention and JCAHO Compliance, “during the programming phase of a construction project, the owner shall provide an Infection Control Risk Assessment (ICRA)” and must ensure that the process takes place and that the recommendations are followed. In other words, for any hospital project there has to be an ICRA or at least documented determination that an ICRA was not necessary.

Sample ICRA Drawing & Key: Project phase drawing from a comprehensive ICRA document

Recycling the same ICRA plan doesn’t work.

ICRA plans often take the form of a generic one-page document that is recycled time and again for every project. And oftentimes, that generic document ends up being a recipe for disaster.

We believe that tailoring each ICRA plan to the project at hand is essential to creating an ICRA plan that works. But you don’t have to start from scratch every time. Drawings will help you view the project from a different perspective so you can identify problem areas that are unique to the project at hand. If your facility has a basic template you like to work from, use drawings of the work zone and surrounding areas to help you create a customized ICRA plan for the project in question.

Before you finalize your ICRA, update drawings to show control measures and other essential project information. And don’t forget to include these drawings in your ICRA package when you share it with facility staff and contractors.

Construction doesn’t happen in a bubble.

And neither does infection prevention. Your ICRA plan should look at the area under construction, but also the facility as a whole. Check where high-risk patient areas are located. Find out where air returns are located. How will the weather affect pressurization? What are your options for emergency egress? Drawings will give you a bird’s-eye view of the facility so you can identify outside factors that might affect the work area, as well as hidden features and small details you could forget working from memory.

You need specifics.

Think back to your last project. Did you have an ICRA document to work with? Was it delivered with the RFP, during pre-construction, or once work had already begun.  Aside from confirming the project title, relative work area and some broad dust control requirements; what did that document do for you?  Did it help with phasing?  Did it help with budgeting?  Did it help with identifying operational constraints that will impact the schedule?  Did it consider existing building conditions that will affect the scope of work? Oftentimes, the answer to these questions is “no,” because you’re working with a generic recycled ICRA plan.

One of the biggest issues with the broad concept measures ‘identified’ in an ICRA, is the absence of a clearly identified path to compliance for the workers in the field.  In other words, those generic ICRA forms are too broad and do not offer enough guidance to workers in the field. This oftentimes leads to a lot of subjective evaluation that ultimately drives the tradesmen to throw up their hands and view ICRA concepts as an impediment to scope execution.

People in the field know drawings.

Written directions don’t always translate, but a map is universally understood. The same goes for your ICRA plans. ICRA drawings serve as a common language for your staff, contractors, engineers, and third-party vendors.

People in the field are comfortable with drawings because they use them on a day-to-day basis. All the detail they need is right there in one place. And let’s be honest here: most people don’t want to read a plan, but they probably will reference a drawing.

These ICRA drawings should be posted at construction entrances so that even the latest tradesmen to join the project are crystal clear on the requirements. When expectations are universally available and understood, we can minimize issues of non-compliance.  After all, the hospital is ultimately responsible for communicating the ICRA plan and ensuring compliance.

When in doubt, map it out.

The main objective of your ICRA should be to control project-related dust, while minimizing effects on surrounding hospital operations.  ICRA drawings will help you determine which control measures you actually need and the best locations to place them.

Here are some factors to consider when determining the best locations for key control measures:

Manometers: We definitely want to know that we are sufficiently negatively pressurized, and also know that we are not too negative. Manometers should be set up outside anterooms and near construction access routes to ensure that the proper balance of negative pressure is being maintained. But we also need to look to the surrounding area for problem variables. For example, we would not want our manometer (and corresponding documentation) to go haywire every time the elevator doors open or when two particular sets of doors are simultaneously opened or closed causing air to rush by from smoke compartment to smoke compartment.

Particulate monitoring: Particulate monitoring should be used at work area entrances to ensure anterooms and temporary barriers are effectively containing dust. In this case, a particulate monitoring location has also been set up outside of a long stretch of temporary barriers that is being used to separate hospital traffic flow from the project work area.

Construction access/debris routes: Construction routes should be planned to minimize travel through patient areas. In this case, ideal times for transport and cleaning have also been notes.

Barrier locations and composition: Ensure that temporary barriers are set up to allow for proper traffic flow necessary for daily operations. Even if the barriers were shown by the Architect, will they functionally work, as shown, given operational constraints?  Did we consider bed swing radius, egress, pneumatic tube stations, etc. in light of barrier placement?  In this case, temporary barriers had to be set up at an angle to allow enough swing radius for hospital equipment to turn the corner.

Traffic flow issues: What equipment needs to be moved? How big is it? Where are the main hospital traffic areas? Patient traffic areas? Are the doors tall/wide enough for construction equipment and building materials? How will debris be removed?

You probably overlooked something.

Use drawings not only to plan placement, but also to identify details that could mess up your ICRA plan. Ask yourself, are high-risk patient areas located nearby? Are the doorways wide enough to fit equipment through? Is project exhaust located near air returns?  What could disrupt manometer and particulate measurements?

Conversely, you can also use drawings to predict how control measures will impact hospital operations and traffic flow. For instance, you may not realize how much of an impediment your barriers will be to functional healthcare delivery until you have already erected them.  You will need to think through the functional needs of hospital staff and facilitate them in your project scope.

Find the safest routes and risky shortcuts.

Use ICRA drawings to map out the safest construction access routes for equipment, supplies and workers. With respect to operational needs and higher risk settings, what is the most efficient route to feed the job? How can we reduce the tracking of dust, dirt and debris through patient areas?  Is this phase near a service elevator?

Once you decide on traffic routes, figure out what route(s) workers will actually take. Do we really think all of our workers will climb five sets of stairs every day, when no one is looking? Shame on us.  We want to figure out what should happen, and then enable that should. 

Double-check: Will your plan work in case of emergency?

Emergency Egress Routing

What will you do if there’s a fire? Or if hidden mold is uncovered during demolition? How will egress be rerouted? Is there a safe path for workers to exit the work area? What equipment will be in the way? What barriers need to be left in place? Use drawings of your ICRA plan to double-check that your plans will work, even in case of emergency.

What should you include in ICRA Drawings?

Your comprehensive ICRA plan should include drawings of the hospital work zone and surrounding areas.  These drawings should include:

• Notations (symbols) showing the locations of control measures such as containment barriers, manometers and particulate monitoring;
• Traffic routes for construction access, hospital staff daily operations and emergency egress;
• Instructions for compliance with Interim Infection Control Protocols (control measures) not otherwise notated;
• Important facility and project information, including need-to-know details about the building and contact information for key project contacts.

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Once you have your tailored your ICRA plan and mapped it out in your construction drawings, you should have a comprehensive ICRA plan that works. As a last step, maximize compliance by sharing ICRA plans and drawings with facility staff and contractors, and by posting ICRA drawings at construction entrances.

For assistance or questions regarding ICRA plans for your next healthcare project, contact Dan Taylor at 800-828-8487.

Claire Foster