ICRA — Infection Control Risk Assessment
The Construction-Phase Document Healthcare Won't Build Without
Every renovation in an occupied healthcare facility starts with two documents: a PCRA covering broad construction risk, and an ICRA covering one specific risk — that dust and pathogens from the work zone don't reach immunocompromised patients. ICRA classifies the work, classifies the patient population, picks a Class I-IV precaution level, and dictates the barriers. ASHE released ICRA 2.0 in 2022 as the current framework. Here's the matrix, the barrier requirements, and what an inspector verifies on the floor.
Why ICRA exists
Hospitals can’t pause patient care for renovation — the ED stays open, the ICU stays full, the OR runs its scheduled cases. Construction happens around occupied space. And construction generates dust, mold spores, fungal spores (Aspergillus is the headline pathogen), and aerosolized debris. To an immunocompromised patient — bone marrow transplant, leukemia, NICU, post-op — those airborne particles aren’t just dust. They’re a fatal infection waiting to happen.
The CDC documented dozens of construction-linked nosocomial infection clusters through the 1990s, leading to the original ICRA framework in 2001 and the joint AIA / CDC / ASHRAE / ASHE consensus that every healthcare construction project, no matter how small, requires a documented infection-control plan tailored to the work intensity and the adjacent patient population. ASHE released ICRA 2.0 in 2022 as the current standard-of-practice framework.
PCRA vs ICRA — what each one is
PCRA
Pre-Construction Risk Assessment — the broad umbrella. Required by NFPA 241 + TJC + CMS for any healthcare construction or renovation.
Covers fire safety (with ILSM as needed), infection control, utility outages, noise/vibration, egress modifications, smoke compartmentation, and hazmat. Owned by the facility / safety team.
ICRA
Infection Control Risk Assessment — the IC-specific component, attached to or referenced by the PCRA.
Classifies the work intensity, the patient risk group, and picks a precaution Class (I-IV). Dictates barrier construction, ventilation, sticky mats, daily monitoring. Owned by the Infection Preventionist (IP).
In practice, healthcare project teams produce both documents at kickoff. Some facilities issue a single combined PCRA/ICRA form; many use separate forms. The IP has authority over the ICRA portion regardless of how it’s packaged — they sign it, they enforce it, and CMS / TJC surveyors will ask the IP for it during a survey of any building with active construction.
The ICRA matrix — work type × patient group → class
The canonical ICRA classification crosses two axes: how intense is the work, and how vulnerable is the adjacent patient population? The cell where they meet gives the precaution Class (I through IV), which dictates the barrier requirements.
Work Type (intensity)
- Type A — Inspection, non-invasive activities. No dust generation. Examples: hanging a picture, plumbing work without cutting walls, electrical trim work where access panels are removed and replaced.
- Type B — Small-scale, short-duration. Limited dust. Examples: opening one ceiling tile, minor cabling work behind one wall, plumbing repair requiring a single chase opening.
- Type C — Work that generates moderate to high levels of dust, or requires demolition/removal of any building component. Examples: cutting drywall for a wall outlet, sanding for finish work, removing floor coverings, ductwork tie-ins.
- Type D — Major demolition and construction projects. Examples: demolition of an entire room, full renovation of a unit, ceiling replacement across multiple compartments, sustained operations over multiple shifts.
Patient Risk Group (vulnerability)
- Group 1 — Low risk. Office areas, public lobbies, non-patient corridors, medical records, parking decks.
- Group 2 — Medium risk. Cardiology, MRI / radiology, physical therapy, nuclear medicine, echo, EKG, outpatient clinics where ambulatory patients are seen but invasive procedures are limited.
- Group 3 — Medium-high risk. Emergency Department, Labor & Delivery, recovery, pediatrics, post-anesthesia care, general medical/surgical wards, geriatrics, dialysis.
- Group 4 — Highest risk. Immunocompromised populations: bone marrow transplant unit, neonatal ICU (NICU), surgical ICU, medical ICU, operating rooms, hematology/oncology, burn unit, dedicated isolation rooms, pharmacy clean room, central sterile.
Resulting Precaution Class — the matrix
| Work Type ↓ / Patient Group → | Group 1 | Group 2 | Group 3 | Group 4 |
|---|---|---|---|---|
| Type A | Class I | Class I | Class I | Class II |
| Type B | Class I | Class II | Class II | Class III/IV |
| Type C | Class II | Class III | Class III/IV | Class IV |
| Type D | Class III/IV | Class III/IV | Class IV | Class IV |
Adapted from ASHE ICRA 2.0 matrix. Where two classes are listed, the higher class applies if the patient group includes severely immunocompromised patients or if the work duration exceeds a single shift. Always defer to the project IP’s judgment.
What each Class actually requires
Class I — Minimum Precautions
- Execute work by methods that minimize raising dust (e.g., wet-cut instead of dry-cut, vacuum drill).
- Replace any displaced ceiling tiles immediately at end of work.
- No barriers required.
Class II — Low-Level Precautions
- All Class I requirements.
- Provide active means to prevent airborne dust from dispersing — water mist, HEPA-filtered local exhaust, dust-suppression mat at the work zone perimeter.
- Wipe work surfaces with disinfectant.
- Block + seal any unused return-air vents during work.
- Place dust mat at entrance + exit of work area.
- Remove or isolate HVAC system in the immediate work area.
Class III — Medium-Level Precautions
- All Class I + II requirements.
- Plastic / vinyl barriers ("zip-walls" or similar) sealed floor to ceiling. Joints sealed with tape.
- HEPA-filtered exhaust providing negative pressure inside the work area, verified daily.
- Anteroom or transition area (single layer of plastic acceptable).
- Sticky mat at egress.
- HVAC isolation — block and seal.
- Daily monitoring + cleaning.
- Material removed in covered carts; debris left in covered containers.
Class IV — Maximum Precautions
- All Class I + II + III requirements.
- HARD-WALL barrier — drywall over studs OR modular panel system (like the photo at the top of this article). Vinyl plastic alone is NOT acceptable for Class IV.
- Full anteroom: enter Class IV zone through an anteroom that itself is also under negative pressure relative to the corridor.
- Negative pressure differential ≥ 0.01 in WC, verified DAILY with a Magnehelic gauge or ball-in-tube indicator.
- HEPA-filtered exhaust running continuously, 24/7. Filter changes documented.
- Sticky mat at the anteroom egress, replaced when soiled (often daily).
- Dedicated entry / exit route — workers do NOT walk through patient corridors. Often through dedicated freight elevator or exterior route.
- End-of-shift cleaning of anteroom + adjacent corridor (HEPA-vacuum + damp mop).
- Material out in covered/sealed carts only. Worker PPE doffed in anteroom; clean clothing donned for exit.
- Daily log of all controls + signatures.
Daily monitoring — what gets checked + logged
- Negative pressure differential. Magnehelic or ball-in-tube. Reads ≥ 0.01 in WC negative inside vs corridor. Recorded with the time + initials.
- HEPA filter integrity. Visual on filter housing (no breaches), airflow indicator on the unit. Filter change date documented on the housing.
- Sticky mat condition. Replace when soiled (often daily on Class IV).
- Barrier integrity. Walk the perimeter — no gaps at floor or ceiling, no propped doors, no breached panels, no unsealed cable penetrations.
- Worker access compliance. Confirm contractors are using the dedicated route, not patient corridors.
- End-of-shift cleaning. Anteroom mopped + HEPA-vacuumed. Adjacent corridor inspected for dust.
- Material handling. All debris in sealed/covered containers; carts wiped before exiting the construction zone.
Common findings on healthcare construction surveys
- Scope drift. ICRA on file describes Class III, but actual work generated Class IV scope. Re-issue the ICRA when scope changes; don’t bury it.
- Negative pressure undocumented. Differential gauge present but no daily log. Or daily log present but the times all match (someone filled it in once). Train + audit.
- Sticky mat too soiled. Mat at end-of-day looks like the construction-zone floor. Replace when soiled, not on a calendar.
- Barrier breaches. Door propped to "ventilate" the work zone. Cable penetration unsealed. Gap at top of barrier where the panel didn’t reach the deck.
- Patient corridor used as primary route. Contractors taking the easy walking path through patient halls instead of the dedicated route. Defeats the entire containment.
- HVAC not isolated. Construction-zone return-air registers still pulling, recirculating dust into adjacent occupied spaces. Block + seal.
- Inadequate PPE. Workers exiting Class IV zone in dust-laden coveralls into the corridor. Doff in the anteroom; PPE goes into a sealed bag.
Where ICRA fits with the rest of the construction-period workflow
ICRA is one of three coordinated risk documents in healthcare construction. They’re siblings, not redundant:
- PCRA — the umbrella covering all construction-period risks (fire, infection, utility, noise, egress).
- ICRA (this article) — the IC-specific module within or alongside the PCRA.
- LSRA / ILSM — Interim Life Safety Measures when construction temporarily impairs life-safety features (fire alarm, sprinkler, egress, smoke compartmentation).
Most projects use all three. The IP signs the ICRA. The Safety Officer / Facility Manager signs the PCRA. The same Safety Officer (often) signs the LSRA. CMS / TJC surveyors expect to see the matched set during any survey of an occupied healthcare facility under construction.
Frequently Asked Questions
How is ICRA different from PCRA?
What is ICRA 2.0?
How do I classify the work and the patients to pick a Class?
What does a Class IV barrier actually look like?
Who signs the ICRA and what authority does it carry?
What is verified daily during construction?
What are the most-cited ICRA findings?
References
1. ASHE — Infection Control Risk Assessment 2.0 (2022). American Society for Health Care Engineering.
2. ASHRAE Standard 170 (current edition) — Ventilation of Health Care Facilities.
3. CDC — Guidelines for Environmental Infection Control in Health-Care Facilities (EICAR, 2003 — still current).
4. FGI / AIA — Guidelines for Design and Construction of Hospitals + Outpatient Facilities (current edition).
5. NFPA 241 — Standard for Safeguarding Construction, Alteration, and Demolition Operations.
6. CMS State Operations Manual — Appendix A (hospitals) + K-Tags (LSC).
7. TJC EC.02.01.01 — Risk reduction in the physical environment.
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