A young man in coveralls walked down the hallway of a building undergoing a remodel. He was a very conscientious craftsman, having worked in quite a few finished tenant improvement spaces. When he arrived to a room that he needed to enter temporarily, he very carefully reached down with both hands and dusted off both pants’ thighs rigorously to remove the dust on his coveralls that had accumulated in performing his work earlier that day. Then he stomped his feet to remove the dust from his shoes and clothing. Like any responsible, meticulous craftsman, he wanted to be sure that he would not get dust in the finished room. The hallway that he was walking down was in the newborn intensive care ward of a hospital. In an effort to be conscientious, this young man unintentionally spread dust and mold spores throughout an area inhabited by patients with highly compromised immune systems.

Hospitals and clinics throughout North America are choosing remodels over new construction due to tight budgets and economic constraints. Remodels can be a lucrative way to capitalize on real estate that is already developed. However, in clinical and surgical settings, seemingly cost-effective tenant improvement projects can impact the bottom line with the smallest mistakes. The uncontained spread of construction dust, debris, mold and overall poor control of infection hazards is a risk for hospital and clinic patients. The spread of dust and mold (especially aspergillus) is a real threat to hospitals and the patients inside.

This issue came on the national radar in 2005, when the Institute for Healthcare Improvement, along with the Center for Disease Control, partnered to form the 100,000 Lives Campaign. This campaign encouraged hospitals and clinics to employ a number of practices designed to reduce deaths resulting from hospital acquired infections. The Institute of Medicine estimates that approximately 100,000 people die each year in U.S. hospitals due to preventable medical injuries, also known as hospital acquired infections. The Centers for Disease Control and Prevention estimate that two million patients suffer hospital-acquired infections each year. Specifically, patients are at a high risk of acquiring some sort of infection from construction related contamination in medical facilities.



There is a great deal of dust and mold in demolition. Apprentices and other less experienced workers are often involved in demolition. Weakest links can spread infection widely and rapidly. On the job site, we often hear the phrase, “just use common sense.” With Infection Control Risk Assessment, something as intuitive as “common sense” gets challenged. Consider the conscientious worker who removes a light switch and finds the back covered in black mold. Shocked, he takes it down the hallway to his foreman to show him the black mold. They discuss its appearance, as well as how to dispose of it. Meanwhile, the craftsman has unwittingly dispersed spores throughout his travel route. The concept of common sense used and expected on most construction jobs needs to be treated more carefully on an ICRA job site. ICRA is a protocol that construction workers can easily follow.

The issue of infection containment should apply to construction contractors, as well as maintenance contractors. A cancer patient in a high-end, well-known hospital recounted this story:

“I was in the oncology ward of the hospital where I was awaiting treatment. Everyone who came into my room had to promise intensely that they were not sick. They all had to wash hands and use a face mask to come in to my room. One day, as I lay in bed, a maintenance worker came into my room. He set up a ladder, climbed up, and pulled down a ceiling tile over my head. I was shocked that he didn’t set up anything to contain his dusty work.”

Witness a ceiling tile removed from an established, existing grid and watch the dust and particles that are released in a cascade when that tile is disrupted. Why wasn’t that maintenance worker trained properly in ICRA?


ICRA is an effort to reduce the risk of contamination when working in occupied healthcare facilities. In order to provide owners with a crew that will be able to perform effectively under these complex conditions, the best tool to address the issue is training.

Effective training is essential to meet the contractors’ and owners’ ICRA needs. As far as this author is aware, a couple unions currently offer ICRA training, as well as some private entities. In looking at interior systems unions, the United Brotherhood of Carpenters offers both carpenter member qualification training and continuing education courses for architects.

Ask any hospital administrator how they are feeling before a major construction project or remodel and they will give similar answers. They believe that construction workers are not aware of how important proper ICRA is to contain infection and mold. With all of this worry, hospitals inevitably devote a tremendous amount of staff time to mitigating construction issues and breaches. It would be naïve to believe that this staff time was not billed, ultimately affecting the bottom line of contractors. As patients and insurers get savvier about hospital acquired infections, there is a growing concern about healthcare facility liability. With liability on the table, hospitals will need to factor that into construction plans. With a proactive approach and the use of ICRA, the liability worries reduce significantly.

According to Mike Stobbe with the Associated Press, “… insurers are pushing hospitals to do a better job and the government’s Medicare program has moved to stop paying bills for certain infections caught in the hospital.”

Hospitals purchase $100,000 machines in order to stay on top of the spread of infection. Hospitals who take ICRA seriously are consistently impressed with a proactive approach. When hospitals experience trained workforces who go into the project with their head in the game, they respond enthusiastically.

After completing a project with ICRA-trained carpenters, Jeffrey Clair, infection control coordinator, University of Pittsburg Medical Center, says, “There is a noticeable difference. Now we are getting the workforce that really understands it, really gets it, and is meeting our needs.”

Contractors who have ICRA trained workforces have a unique bidding opportunity in the hospital/clinic market. However, the contractors are not alone in the risk. While unions typically offer the training free to the contractor’s workforce (compared to rather expensive private qualification programs), bidding healthcare jobs can be a hurdle if there is not some assurance that it will be worthwhile to factor in all of the containment time and other ICRA precautions in the bids. This is where a contractor’s partnership with the owners and architects is an important piece of the ICRA recipe. Owners can, and have, developed ICRA policies that are part of the bid requirements for contractors. With those policies in place, unions and contractor associations can provide the workforce training to complete the puzzle.

 The strategy must be multi-pronged to get this problem under control and ensure that owners have a well trained workforce who is able to address the construction challenges. To be successful, the effort to reduce the risk of spreading contamination in hospitals and clinics needs to be embraced on all levels. This translates into owners, developers, architects, contractors and labor organizations making an investment towards the solution.