Beyond the Barrier: How ASHE ICRA 2.0® Strengthens Infection Prevention During Healthcare Construction and Renovation

Healthcare facilities are never truly static. Hospitals renovate operating rooms, replace mechanical systems, open new procedural areas, repair ceilings, install technology, modify plumbing, and perform countless maintenance activities every day. Yet even relatively routine work can create an infection prevention challenge when it occurs in an occupied healthcare environment.

Opening a ceiling, disturbing drywall, changing airflow, accessing utility spaces, or demolishing existing structures can release dust and microorganisms into the environment and alter carefully designed pressure relationships. For highly vulnerable patients and for the healthcare workers caring for them, those disruptions can create potentially serious exposure risks. That is why the American Society for Health Care Engineering (ASHE) developed ICRA 2.0®, an updated Infection Control Risk Assessment process designed to bring infection prevention directly into the planning and execution of construction, renovation, maintenance, and operational activities. ASHE describes the purpose of the process as ensuring that patients, staff, workers, and visitors remain appropriately protected from infectious risks while healthcare facilities improve the physical environment.

ICRA Is a Process, Not Simply a Form

One of the most important concepts surrounding ICRA 2.0 is that completing a matrix does not, by itself, constitute an effective infection prevention program. ASHE emphasizes that full implementation requires an interdisciplinary team to identify risks, select mitigation strategies, communicate expectations, monitor compliance, and maintain controls from before work begins through project completion.  

That collaborative approach is critical. Infection preventionists understand patient susceptibility and transmission risks. Facilities and engineering professionals understand ventilation, pressure relationships, utilities, and building systems. Environmental services bring expertise in cleaning and disinfection. Clinical leaders understand the populations occupying the surrounding areas. Contractors and project managers determine how work will be performed. ICRA 2.0 brings those perspectives together before exposure occurs rather than after a problem has already developed.

How the ICRA 2.0 Process Works

The ICRA 2.0 matrix begins by categorizing work based on its potential to generate dust, debris, disruption, and environmental contamination. Activities range from Type A, such as inspection and noninvasive work that creates essentially no dust, through Type D, which includes major demolition, large-scale construction, and significant building-system work.

The team then considers the people who could potentially be exposed. ICRA 2.0 divides patient areas into low-, medium-, high-, and highest-risk patient groups. Highest-risk environments include areas such as transplant and intensive care units, oncology units, operating rooms and restricted areas, procedural suites, pharmacy compounding, and other settings where patients may be highly compromised, or invasive and sterile procedures are performed.

The activity type and patient-risk group are then combined to determine a Class of Precautions ranging from Class I through Class V. As risk increases, so does the intensity of required mitigation. Importantly, the assessment does not stop at the construction boundary. ICRA 2.0 also specifically evaluates areas above, below, besides, behind, and in front of the project and considers issues such as dust, ventilation, pressurization, vertical shafts, elevators, stairs, water systems, medical gases, and other infrastructure. This broader perspective recognizes a fundamental reality of healthcare construction: air, dust, people, equipment, and microorganisms do not necessarily remain inside the lines drawn on a construction plan.

Why Air Is Such an Important Part of the Equation

 The Centers for Disease Control and Prevention has long warned that construction, renovation, demolition, and repair can increase airborne fungal spore concentrations in healthcare environments. Disturbing dust, soil, ceiling spaces, and building materials can aerosolize organisms such as Aspergillus, creating particularly serious risks for immunocompromised patients. CDC therefore recommends conducting an infection-control risk assessment before construction begins and implementing appropriate controls for dust, moisture, ventilation, and containment.

ICRA 2.0 reflects this risk by progressively strengthening engineering controls as project risk increases. Class III precautions require active measures to prevent airborne dust from dispersing into occupied areas and may include HEPA vacuuming, containment, isolation of supply and return air, and maintaining contained spaces at neutral-to-negative pressure. Classes IV and V introduce more robust critical barriers, controlled airflow patterns, negative pressurization, HEPA-filtered exhaust when indicated, and continuous pressure monitoring.

These precautions reinforce an important infection prevention principle: contaminated air should be controlled as close to the source as possible.

Air Disinfection as Part of a Layered Strategy

Construction containment and proper HVAC management remain foundational and should never be replaced by supplemental technology. But healthcare organizations should also think more broadly about the quality of air in occupied spaces surrounding construction projects. Supplemental air cleaning and air disinfection can provide an additional layer in a comprehensive risk-reduction strategy. CDC guidance recognizes portable industrial-grade HEPA filtration as an engineering control to augment the removal of respirable particles when appropriate, and recognizes ultraviolet germicidal irradiation as a supplemental engineering control in specific healthcare applications.

Similarly, ASHRAE Standard 241 describes ventilation and air-cleaning systems as tools for delivering equivalent clean airflow and reducing exposure to infectious aerosols. For healthcare organizations, this creates an opportunity to think about air protection beyond the construction enclosure itself. Risk-based use of continuous or portable air-cleaning technologies may be considered in occupied spaces where patient vulnerability is high, airflow is temporarily disrupted, patient traffic has been redirected, or additional reduction of airborne contaminants would provide value. These technologies should be viewed as adjuncts, not substitutes, for required ventilation, pressure relationships, critical barriers, source control, and other ICRA precautions.

ICRA 2.0 Does Not Replace Core Infection Prevention Practices

Construction-related infection prevention must also remain connected to the fundamentals of safe healthcare delivery. CDC Core Infection Prevention and Control Practices include hand hygiene, environmental cleaning and disinfection, appropriate use of personal protective equipment, respiratory hygiene, safe handling of equipment, and ongoing monitoring of infection prevention performance. 

During construction, those fundamentals become even more important. Dust can settle on environmental surfaces. Workers and equipment can transport contaminants beyond the work zone. Temporary traffic patterns can create unexpected interactions between construction personnel, healthcare workers, visitors, and patients. Airflow changes can affect areas far removed from the immediate project.

The safest strategy, therefore, layers interventions: appropriate barriers; ventilation and pressurization; HEPA filtration where required; air cleaning or disinfection when risk assessment supports it; environmental cleaning; hand hygiene; PPE; traffic control; education; surveillance; and continuous verification that controls remain effective.

ICRA 2.0 also emphasizes what happens after construction activities end. Higher-risk projects require inspection before precautions are downgraded; work areas must be thoroughly cleaned; barriers must be removed in ways that prevent dust from being released; negative-air devices may need to remain operational after dust-generating activities; and HVAC systems must be verified as clean, functional, and meeting their intended airflow and air-exchange specifications.

Building Infection Prevention into the Environment

Perhaps the greatest value of ASHE ICRA 2.0 is that it changes infection prevention from a reactive activity into a proactive design and operational discipline.

The question is no longer simply, “Can we complete this project?”

It becomes, “How can we complete this project while maintaining a safe environment for every patient, healthcare worker, contractor, and visitor who may be affected?”

That distinction matters.

Healthcare construction is inevitable. Cross-transmission is not. By combining the structured risk assessment of ICRA 2.0 with rigorous engineering controls and core infection prevention practices, including thoughtful management and disinfection of the air that healthcare professionals and patients breathe, healthcare organizations can continue transforming their facilities without compromising the people those facilities exist to protect.