Construction, Water & Air: The Environment Is Not Neutral
Air handling, water systems, and construction activity are infection prevention controls. Each creates transmission pathways that hand hygiene, transmission-based precautions, and device bundles cannot close. When these systems fail, they fail quietly, and the resulting cases are often attributed to clinical practice rather than to the building.
The evidence on construction is direct. In a foundational systematic review of nosocomial aspergillosis outbreaks — 53 studies, 458 patients — construction or demolition work was the probable or possible source in 49.1% of outbreaks. Among severely immunocompromised patients, the fatality rate was 57.6%. One tertiary-care hospital tracking invasive mold infections recorded 3.0 cases per year before construction and 5.6 during it.
The exposure required is smaller than most people assume. Concentrations below a single colony-forming unit per cubic meter have been sufficient to cause infection in high-risk patients. This is not a visible dust problem.
The patients these controls protect are the ones with the least margin — hematology, transplant, ICU. They are also, usually, nowhere near the construction. Spores travel; patients don't have to.
There's a common thread running through all three of these domains, and it isn't technical. Air, water, and construction sit between infection prevention and facilities, and in most organizations neither department fully owns them. Infection prevention holds the regulatory obligation and no authority over the building. Facilities holds the building and no surveillance data. The ICRA permit is often the only artifact that crosses between them.
Reducing infection risks related to construction, renovation, and repair
Most infection preventionists have had some version of this conversation. A permit appears in your inbox on a Thursday. The project starts Monday. You've never seen the drawings, nobody asked what's on the other side of that wall, and the person who sent it isn't cutting corners — they assumed this step was a signature. In most organizations, that assumption is correct. And that's the problem.
The infection control risk assessment was introduced in the 1996 Facility Guidelines InstituteGuidelines for Design and Construction and has been standard practice for nearly three decades. The American Society for Health Care Engineering rebuilt the process as ICRA 2.0, structured as five steps completed at the onset of project design, before any work begins.
Signs the process has become paperwork rather than prevention:
Infection prevention sees the project at permit stage rather than design phase
No one re-assesses when scope changes mid-build
Barriers, negative air machines, and traffic routes are verified at installation but not during the work
The contractor receives the permit, but no one confirms the crew understands what it's for
The failures themselves are usually mundane and visible. A barrier with a gap at the ceiling tile. A negative air machine unplugged so someone could run a floor buffer. A door propped for cable access. An anteroom used as a break area because it's the only quiet space on the unit. An ICRA completed after the schedule is fixed can document risk. It cannot reduce it.
The timing is part of why this goes unrecognized. Cases don't appear while the barriers are up. They appear after the project closes out, once the dust has settled and everyone has moved on. By then, nobody is connecting a case in hematology to a wall that came down in March.
Water management programs
Since 2017, the Centers for Medicare & Medicaid Services has required hospitals, critical access hospitals, and long-term care facilities to maintain water management programs to reduce Legionella risk, under memo QSO-17-30 (revised July 2018). Programs must be based on ASHRAE Standard 188 and the CDC toolkit, and must specify testing protocols, acceptable ranges for control measures, and the corrective actions taken when those ranges aren't maintained.
The document almost always exists. The harder questions are operational:
Who reviews control measure results, and how quickly does an out-of-range finding reach infection prevention?
Are low-use water sources — closed units, rarely used showers, decommissioned rooms — on a documented and verified flush schedule?
Does the program get re-evaluated when construction disturbs the water system, or only on an annual cycle?
That last question points to a well-documented gap. Construction affects water systems as reliably as it affects air, and most water management programs weren't designed to account for project work. Published tools now exist to extend ICRA thinking to waterborne pathogens, but adoption remains uneven.
Air balance and ventilation
Ventilation requirements in healthcare settings are specified by room type and use. Pressure relationships, filtration, and air change rate requirements differ for operating rooms, airborne infection isolation rooms, sterile processing areas, and protective environments. Renovation changes rooms. So does function. A storage room may have been converted to procedure space, an isolation room taken offline during a census surge, or a corridor door propped open for equipment access, but none of these would likley have triggered an airflow review, and pressure relationships may drift.
One practical exercise: pull your room pressure monitoring log and compare it against a current list of what each room is actually used for today. The mismatches are the finding - a room monitored as negative that's now storing sterile supplies, or a room that changed function two renovations ago and is still being monitored against its original specification. Take the list to your facilities partner rather than to a committee, most of these are correctable, and the conversation is considerably easier before they come up in a survey finding.
The environment is not neutral
The built environment of your facility either supports your infection prevention program or quietly works against it, and the difference is rarely visible from a policy binder or a chart review.
If your facility is planning updates, or has renovated, repurposed space, or changed service lines in the past few years, an infection prevention gap assessment can identify where the physical environment has drifted from what your program assumes. IP&MA reviews construction and renovation processes, water management implementation, ventilation and pressure relationships, and the workflows that move through those spaces. We deliver a written findings report with prioritized, practical recommendations, or support you through the full construction and renovation process.
Request a discovery call to talk through a walkthrough of your facility.