Healthcare design in the wake of COVID-19
Healthcare facilities will be looking at key learnings from this time to better host the public in safe and effective ways now and in the future as they move forward from COVID-19.
As the world discusses how to reengage our society in the wake of COVID-19, healthcare facilities will be looking at key learnings from this time to better host the public in safe and effective ways now and in the future. There are many ways spaces within hospitals and other healthcare facilities can be modified to make them safer for patients and visitors. Focusing on solutions that don’t require a complete reinvention or major renovation of the facilities, healthcare design experts at Henderson Engineers have taken a look at some of the most crucial spaces through the lens of infection control technologies with respect to the three transmission vectors: surfaces, airborne, and droplets. Below we’ve outlined how infrastructure and building systems master planning will be invaluable in preparing healthcare facilities for future infectious disease response.
Operating rooms (ORs) are a discussion topic in healthcare design every time the world is threatened by a pandemic because patients still require procedures, sometimes while they are still infectious. The first response it typically to create a fully exhausted OR with an anteroom in an attempt to protect the other building occupants against cross contamination. However, this solution is very expensive in upfront investment as well as operating costs and is not feasible with most existing building systems without compromising environmental conditions such as temperature and humidity.
Instead, many facilities and professional organizations recommend either the addition of a procedural 30 minute delay after intubating and extubating a patient, the greatest risk for respiratory virus spread in the OR suite, to allow the room airflow to flush the space of aerosolized particles before any other staff can renter the room or performing these procedures in a remote negative pressure room. These strategies create their own challenges, though.
- Increases the time of each procedure by 1 hour, therefore reducing the number of cases that can be performed having a financial impact to health system.
- Microbes that settle on surfaces within the space can be transmitted outside the operating room as staff moves to other parts of the OR suite.
- Microbes could transmit to the central operating room HVAC system.
- Intubating in a remote negative pressure room can put the patient at additional risk during transport to the operating room.
A combination of the following tactics in healthcare design can be taken to address these challenges.
- Creating a line of demarcation within an operating room, where a second layer of PPE is donned upon entering and removed upon leaving, would allow staff to remain in PPE within the sterile core without transmitting surface contamination to other portions of the OR suite.
- Utilizing a localized exhaust snorkel, which are commonly used in labs, during intubation to capture any aerosolized particles at the source before they land on surfaces or transmit to the HVAC system. These could be portable units with HEPA filtration or permanently installed in the ceiling with exhaust to a dedicated exhaust fan. This exhaust would only require around 100 CFM per snorkel, while greatly reducing the impact on the room and system as a whole.
- Enhancing filtration within the HVAC unit coupled with UV to inactivate viruses will protect other rooms from cross contamination should a microbe be transmitted through the return air system.
- Implementing a combination of portable and permanently installed Ultraviolet Germicidal Irradiation (UVGI) systems can decrease the time it takes to terminally clean a room after use for an infectious patient.
- Installing new HVAC systems with capacity to increase airflow and number of air changes per hour (ACH) in a purge mode can reduce the waiting time between procedures required by some facilities, increasing the number of procedures performed each day.
Emergency departments and urgent care facilities
Emergency departments (ED) and urgent care facilities are the true front lines of infectious diseases, creating a virus transmission concern for healthcare workers and other patients with noninfectious infirmities like broken bones, stitches, etc. Within most waiting rooms, patients can sit in any location which makes it difficult for the facility to know where to focus cleaning and can make families uneasy about utilizing these services. The operation and healthcare design strategies below may assist in reducing transmission of infectious diseases and give an increased comfort level to patients.
- Increasing the number of isolation or triage spaces enables these facilities to keep infectious patients separated.
- Employing technology to allow patients to wait in a vehicle and be notified when they are ready to enter the facility.
- Utilizing local air cleaning technology within the waiting room.
- Installing a combination of UVGI technologies to inactivate viruses in the airstream and on surfaces.
- Altering the location of exhaust in ED waiting rooms. Currently ED waiting rooms are required to be exhausted by code to reduce cross contamination within the facility, but this airflow is not typically arranged to maximize the extraction of any microorganisms from the space. Locating the exhaust at a floor level location in these facilities with supply in a location to provide favorable airflow patterns would make these spaces more effective at reducing cross contamination.
- Utilizing screening and assigned seating based on the symptoms presented upon arriving. This would give well patients a higher level of comfort and allow the facility to target their sanitation efforts. If assigned seating places infectious cases near the HVAC exhaust and noninfectious cases are seated near the HVAC supply, cross contamination is reduced to an even greater degree.
Patient suites (Existing construction)
When considering healthcare design in hospitals, patient suites are of great importance with regard to infection control. During the COVID-19 pandemic, many hospitals converted existing patient rooms to negative isolation rooms. Some spaces were converted utilizing temporary measures such as a fan filter unit and others added a central exhaust fan for a more permanent solution. As these spaces are converted back to standard patient rooms, a few items should be considered to keep them flexible for possible future use.
- Review the existing air handling unit (AHU) and verify it will be able to accommodate additional makeup air during the summer months.
- Evaluate existing air distribution in patient rooms to determine if supply and exhaust can be modified for better contaminant containment.
- Examine the existing oxygen and medical air systems to determine how many ventilators the floor or department/unit can support.
Patient suites (New construction)
New construction or expansion projects present more opportunities to create flexible patient suites. Creating spaces with the flexibility to change patient rooms to be fully exhausted quickly or improve room airflow patterns to reduce cross contamination, as well as designing rooms to minimize surface cross contamination, is beneficial in preparation for infectious disease response. While the considerations below may cost more upfront, facilities will have more flexibility to respond when the need arises, saving money and time when the need is greatest.
- Return air ducts that are dedicated to patient rooms so they can be provided with dampers in the mechanical space allowing transfer to an exhaust fan.
- Dedicated exhaust fan for patient toilets so they can be utilized as an isolation room without much modification.
- Secondary cooling coil in patient room AHUs to allow increased makeup air if rooms are transitioned to isolation rooms.
- Unidirectional airflow within patient rooms to better manage airflow patterns within the space.
Medical gas systems
- Oversized medical gas piping in patient rooms to be prepared for increased usage for illnesses requiring ventilators.
- Integrated technology to allow more control from a patient’s mobile device, removing touches required within the rooms such as door handles, light controls, entertainment, etc.
- Isolation and pressure control between clean and dirty patient areas utilizing natural separation required by the smoke compartments on the patient floor. Consider the location of nurse stations with respect to these separations to reduce cross contamination.
In addition to the specific departments and spaces in healthcare design, there are also infrastructure related upgrades that can be implemented to assist in preparing a facility to treat infectious disease patients.
- Portable/localized air cleaning equipment in spaces of high concentration or with a probability to house infectious patients.
- Dedicated air handling equipment for departments to reduce the risk of airborne transmission.
- Advanced filtration or air cleaning in AHUs serving multiple departments.
- Surface decontamination with UV where infectious patients are evaluated or treated.
- Auxiliary connections to medical gas systems to add increased capacity as required. It’s also important to evaluate the capacity of medical gas systems for maximum demand in each department.
- Technology infrastructure to handle increased telehealth visits for staff officed within the hospital or healthcare facility and remotely.
- Touchless controls where possible such as doors, lighting, elevators, etc.
A facility infrastructure and buildings systems master plan can help the process of determining what post COVID-19 options are available for infectious disease treatment in healthcare designs.