Infection Control Risk Assessment (ICRA) for Construction

An infection control risk assessment (ICRA) is the required process healthcare facilities use before any construction, renovation, or maintenance activity to determine what infection-control precautions the work needs — dust and moisture generated during construction can aerosolize fungal spores (notably Aspergillus) and other pathogens that pose a direct risk to immunocompromised and other vulnerable patients nearby. ICRA is not a single inspection; it is a structured, repeatable risk matrix that combines the type of construction activity with the patient population it will affect, producing a defined class of required precautions, and it is a prerequisite step embedded in the Facility Guidelines Institute (FGI) Guidelines for Design and Construction of Hospitals and Outpatient Facilities and referenced in Joint Commission accreditation standards for the physical environment.

The Risk Matrix: How It Works

The ICRA process, as codified by the American Society for Health Care Engineering (ASHE) and widely adapted by facilities and infection-prevention organizations (including APIC), runs in three steps.

Step 1: Classify the Construction Activity Type

Type	Description
Type A	Inspection and non-invasive activities — limited ceiling-tile removal for visual inspection only, painting (not sanding), minor plumbing or electrical trim work that does not generate dust or require cutting into walls or ceilings.
Type B	Small-scale, short-duration activities that create minimal dust — cabling installation, access to chase spaces, cutting into walls or ceilings where dust migration can be controlled.
Type C	Work generating a moderate-to-high level of dust, or requiring demolition or removal of fixed building components — sanding for painting, removal of floor coverings/ceiling tiles/casework, new wall construction, minor duct or electrical work above ceilings, or any activity that cannot be completed within a single work shift.
Type D	Major demolition and construction projects — work requiring consecutive shifts, heavy demolition, removal of a complete cabling system, or new building construction.

Step 2: Identify the Patient Risk Group Affected

If the work affects more than one risk group, the assessment uses the higher (more sensitive) group.

Risk group	Representative areas
Low	Office areas
Medium	Cardiology, echocardiography, endoscopy, nuclear medicine, physical therapy, radiology/MRI, respiratory therapy
High	Emergency room, labor and delivery, medical units, newborn nursery, outpatient surgery, pediatrics, pharmacy, post-anesthesia care unit, surgical units
Highest	Any area caring for immunocompromised patients, burn unit, cardiac cath lab, central sterile supply, intensive care units, negative-pressure isolation rooms, oncology, operating rooms (including C-section rooms)

Step 3: Cross-Reference the Matrix for the Required Class of Precautions

The construction type and patient risk group are crossed on a matrix to yield a required class of precautions — commonly Class I through Class IV in the original ASHE/APIC matrix widely used across facilities, with ASHE’s revised ICRA 2.0 (2022) refining activity-type and risk-group definitions and adding a fifth precaution tier. In the original four-class structure, low-risk construction activity in a low-risk area (Type A in a Low Risk Group area) requires only Class I precautions, while any Type D (major demolition/construction) work requires Class IV precautions regardless of the area’s risk group, and higher-risk combinations in between step up accordingly — for example, Type C work in a Highest Risk Group area, or Type D work anywhere, both trigger the facility’s highest level of infection-control approval requirement. Class III and Class IV determinations require a documented infection control permit and sign-off before work can proceed — this approval gate, not just the precaution description, is the operational teeth of the process.

What the Precaution Classes Actually Require

Precautions escalate in scope from Class I to Class IV, broadly following this structure (facilities should reference their own current ICRA policy and, where available, ASHE’s ICRA 2.0 materials for exact current wording):

• Class I — execute work using methods that minimize dust; immediately replace any ceiling tile displaced for inspection.
• Class II — add active dust-control measures: water-mist work surfaces when cutting, seal unused doors, block and seal air vents, isolate or remove HVAC in the work area, and clean the area (wipe surfaces, contain and cover waste, HEPA-vacuum) on completion.
• Class III — isolate the HVAC system serving the work area to prevent duct contamination, complete full critical barriers (sheetrock, plywood, or sealed plastic) to separate the work site from occupied areas, maintain negative air pressure within the work site using HEPA-equipped filtration units, and require inspection and thorough cleaning by environmental services before barriers are removed.
• Class IV — the same isolation and negative-air-pressure controls as Class III, applied at full scope for major demolition/construction, with the most stringent barrier, containment, waste-handling, and closeout-inspection requirements.

Across every class, containment waste is transported in covered receptacles, and barriers are not removed until the completed work area is inspected by the facility’s safety and infection prevention departments and cleaned by environmental services — closeout is as much a defined, documented step as the precautions taken during the work itself.

The Step-by-Step Process in Practice

1. Project scoping. Facilities/construction management identifies the planned work and its physical scope before mobilization.
2. Joint assessment. Infection prevention, facilities engineering, and the project’s construction/contractor representative jointly classify activity type and affected patient risk group(s) using the matrix.
3. Precaution class determination and permit. The matrix output determines the required precaution class; Class III/IV work requires formal infection-control permit sign-off before work begins.
4. Implementation and monitoring during work. Barriers, negative-air equipment, and HVAC isolation are installed and verified before invasive work starts, and infection prevention or facilities staff conduct periodic monitoring (visual barrier integrity checks, negative-air-pressure verification) for the duration of the project.
5. Reassessment on scope change. If the actual scope of work expands or changes beyond what was originally assessed, the ICRA is expected to be redone for the new scope — the original sign-off does not automatically extend to added or different work.
6. Closeout inspection. Infection prevention and safety departments inspect and approve the completed, cleaned area before barriers are removed and the space is returned to clinical use.

Common Failure Points

• Treating ICRA as a one-time paperwork step rather than an ongoing monitoring obligation for the duration of the project.
• Not reassessing when scope changes mid-project — a Type B project that turns into Type C work without a new sign-off is a documented, recurring compliance gap.
• Inadequate barrier construction or maintenance — barriers that are not actually sealed, or that degrade over a multi-week project without inspection.
• Missing infection-prevention approval for Class III/IV work, or treating facilities/construction sign-off as sufficient on its own.
• Failing to verify negative air pressure within the work site is actually being maintained throughout the project, not just installed at the start.
• Overlooking a nearby AIIR or other sensitive space whose own function depends on undisturbed HVAC balance — construction elsewhere in a building can affect an unrelated room’s negative-pressure performance if HVAC zones are not properly isolated; see our companion guide on airborne infection isolation rooms (AIIR) for the specification a nearby isolation room needs to keep meeting during and after adjacent construction.

Where This Requirement Comes From

ICRA is embedded as a required process in the current Facility Guidelines Institute (FGI) Guidelines for Design and Construction of Hospitals and Outpatient Facilities, the document most U.S. state licensing authorities reference or adopt for healthcare facility construction. It is also referenced through Joint Commission Environment of Care standards, which expect facilities to conduct and document a proactive risk assessment before construction affecting patient care areas. The FGI Guidelines themselves are a purchased, copyrighted document rather than freely published online — the matrix structure described here (activity type × patient risk group × precaution class) reflects the widely used ASHE/APIC-format ICRA matrix that most U.S. facilities’ own policies are built on, but the current, authoritative figure-level requirement for any specific project should be confirmed against the current FGI Guidelines edition and the facility’s own ICRA policy rather than a secondary summary.

Frequently Asked Questions

What does ICRA stand for?

Infection control risk assessment — the pre-construction process healthcare facilities use to determine required infection-control precautions for a construction, renovation, or maintenance project.

Who has to sign off on an ICRA?

Typically infection prevention and facilities/safety leadership jointly, with Class III and Class IV precaution determinations specifically requiring a documented infection-control permit before work can begin.

Does every construction project need an ICRA?

Yes — even minor, low-risk work (Type A activity) goes through the classification step, though it results in the lightest precaution tier (Class I). The point of running every project through the matrix is that risk is a function of both the activity and the area affected, not something staff should judge informally case by case.

What happens if a construction project’s scope changes partway through?

The ICRA should be reassessed for the new scope. A sign-off issued for one activity type does not automatically cover expanded or different work discovered or added later in the project.

How is ICRA different from an AIIR specification?

ICRA is a process for assessing and controlling infection risk during construction activity generally. An airborne infection isolation room (AIIR) is a specific finished-room engineering specification (negative pressure, air changes per hour, exhaust handling). Building or renovating an AIIR goes through ICRA during construction, and is separately commissioned and verified against the AIIR specification once complete.

See also High-Level Disinfection and the Spaulding Classification, the infection preventionist role that typically leads ICRA sign-off, and the patient safety and infection prevention pillar.