Healthcare / Service redesign
Why ORs offer distinct opportunities for COVID-19 patients who need isolation
24 Apr 2020 | 0
Doug King, a principal in the Healthcare Practice Group of Stantec and an expert on isolation hospitals, examines some of the options available to hospitals looking to increase their patient capacity to cope with COVID-19.
As a result of the COVID-19 pandemic, many hospitals are exploring alternatives that increase the number of spaces that can accommodate patients, both those with active coronavirus infection and those requiring observation and testing.
The American Society for Healthcare Engineering (ASHE) has created a resource page – covering critical aspects of operations, such as air quality and infection prevention to assist healthcare facilities professionals in their efforts to reduce the spread of COVID-19. The Society’s resources prompted our team of healthcare designers to think about the spaces hospitals need for COVID-19 treatment.
While we see that various large spaces (arenas, conference centres, etc) are being used for COVID-19 treatment, there are other opportunities to convert existing spaces at the hospital quickly to accommodate many of these patients. Obviously, a hospital environment provides the best setting for both patient and the caregiver.
Healthcare institutions around the world are trying to quickly increase the number of patient rooms that can accommodate COVID-19 patients. Here follows some of the options available to hospitals that have been developed and vetted with regulatory agencies in the US.
Converting operating rooms
For many hospitals, converting operating rooms (ORs) within hospital settings and ambulatory surgical centres is a promising solution that offers immediate increase in the number of rooms for COVID-19 patients. These OR spaces are currently underutilised due to a reduced emphasis on elective surgeries. They are already outfitted with the appropriate air changes and air pressure. OR rooms can be converted to double-patient isolation rooms. In fact, the anaesthesia equipment in these spaces is readily available for ventilator support, with only one additional ventilator needed.
These rooms typically have existing equipment booms that can be used for the installation of plastic shielding between patient beds. This allows the room’s conversion into multiple isolation patient rooms to house those with a similar diagnosis.
These existing OR room systems, however, must be negative pressure and HEPA (high-efficiency particulate air) filtered. If the facility does not have a central HEPA-filter bank, it may be necessary to install a HEPA-filter box at the return air grille so that it filters the exhaust (the aerosols created by aspiration treatment) to the outside of the building. We don’t want to remove virus-contaminated air only to spray it outside or back into the facility. There is a high likelihood that these HEPA filters are already available on the medical campus through contractors or testing and balancing agents.
Broadly speaking, hospitals will need four categories of space in order to comprehensively manage patient needs during this pandemic:
- Spaces for patients with COVID-19 virus that need aspiration. According to the ASHE, airborne infection isolation rooms (AIIRs) should be reserved for patients who are undergoing aerosol-generating procedures. These AIIRs must be isolation-room spaces that direct moisture-laden air out of the room and away from the patient and caregiver. At the same time, they also remove particles with HEPA filtering and replenish the air in the room quickly, with 12 high-air changes each hour.
- Spaces for patients with COVID-19 virus who don’t need aspiration. These spaces must have HEPA-filtered, negative-air machines, with room air replenished by less than 12 air changes per hour.
These two types of spaces (highlighted above in points 1 and 2) are likely already available in the hospital or an ambulatory care centre – but they would need to be repurposed to accommodate COVID-19 infected patients, necessitating additional design considerations.
- Spaces housing patients who haven’t been diagnosed yet but are under observation, or patients who are recovering. These spaces have HEPA-filtered, negative-air machines and require less than 12 air changes per hour.
- Triage and testing spaces that are proximate to the medical facility. These do not have criteria for HEPA and air-change requirements.
The first category of spaces above, AIIRs with filtering, will be needed to treat the most critically ill. Care facilities need spaces that can accommodate the roughly 20-25 per cent of COVID-19 patients who will be on ventilators. Because ventilators produce air that is contaminated by aspirated fluid, they must be kept in isolation with air systems that can dissipate the contaminated air flow quickly. These spaces must release moisture into the air, have HEPA-filtered air, and accommodate high air changes as well as negative pressure.
Unfortunately, most hospitals do not have enough dedicated AIIRs. Usually, hospitals in the US (by code) have about 10 per cent of their patient rooms set up as isolation rooms, roughly less than half of what will be needed to accommodate COVID-19 patients. A 1000-bed hospital at a major medical centre might have about 100 AIIR rooms but will likely need a total of 200 to 250, at minimum, to meet the expected demand.
Ideally, these conversions will be approved by relevant agencies, such as the local state departments of public health and the Centers for Medicare & Medicaid Services (CMS). The CMS and state public health agencies will be looking for compliance with the Centers for Disease Control and Prevention (CDC) requirements for the design of AIIR spaces, and will be interested in other patient-care rooms having negative pressure.
Generally, the regulatory reviewers have stated that the clinical care mission drives the space requirements. The good news related to these needs is that most local jurisdictions are suspending permitting requirements for temporary healthcare space reconfigurations at this time. Regulatory agencies are letting healthcare institutions define what needs to be built to protect the caregivers and patients within their institutions.
The need to act fast
If our group’s intuition is correct, there is a lot of operating room spaces in the US that qualify for these conversions. We need to act fast to increase the quantity of COVID-19 spaces for patients on ventilators, and fortunately that conversion is not labour-intensive. It can be done with materials readily available to hospitals and can quickly increase the volume of isolation rooms available for treating COVID-19 patients. We need to quickly and efficiently take advantage of our existing spaces and infrastructure, allowing our healthcare professionals to focus on providing care in this time of crisis.
About the author
Doug King is a leader in Stantec’s health practice with extensive experience in healthcare design for institutions covering a broad range of delivery.