Creating More Resilient Healthcare Facilities

As health care facility managers navigate these changes, many are focused on building stronger levels of flexibility and resiliency to more rapidly navigate the COVID-19 crisis to ensure the safety of patients and staff. There are several key considerations to address today to successfully achieve this level of flexibility tomorrow.

Initial options

At the onset of the pandemic, hospitals focused solely on surge capacity. FMs were tasked with converting inpatient, outpatient and other units into areas dedicated to serving COVID-19 patients. The goal for most facilities was to create dedicated floors or wings for COVID patients, and HVAC systems played a key role in containing the infection within these dedicated areas.

Although the U.S. Centers for Disease Control and Prevention (CDC) has required negative pressure rooms only for aerosol-generating procedures, many, if not most, healthcare facilities developed temporary negative pressure rooms to manage COVID-19 patients. In some cases, this was done through converting HVAC systems, in other cases using portable negative air machines.

Those HVAC conversions took several forms. Some facilities successfully adjusted the dampers within the air handling unit supplying patient rooms, converting the original mixed air, recirculating design to a 100 percent outdoor air system. Others supplemented the air handling unit adjustments with air balancing at the room level. To create an isolation room type-space, a testing and balancing contractor was brought in to adjust the air handling unit dampers and the room exhaust airflow to ensure that these spaces were maintaining negative pressure conditions. For an experienced professional team that included a control contractor and air balancing contractor, these conversions may take one to two days.

Limitations & considerations

There are serious limitations to address in converting air handling systems entirely into 100 percent outdoor air systems. During the initial phases of the coronavirus pandemic (February and March 2020), these conversions were possible given the cooler outdoor air temperatures at those times and locations. During periods when outdoor air temperatures are more extreme (significantly warmer or colder), most air handling systems would be unable to adequately condition the incoming outdoor air. Implementing this solution deep into the summer or winter season in most regions would not be possible and may require FMs to rely most on high-efficiency filtration at the air handling unit and through portable HEPA filtered air units exhausting to outdoors from individual rooms.

For healthcare facilities that may rely solely on portable HEPA filtered air units to convert these spaces to negative pressure, it is important to recognize that many portable HEPA filtered air machines are used on construction sites for construction containment purposes. These units are often used to capture potentially contaminated air within the construction site work environment, thus preventing it from transferring to occupied areas. It is important that these units are appropriately cleaned prior to being used in healthcare spaces occupied by patients or staff. It is also important to operate “right sized” HEPA filtered air units within the areas as operating oversized units can lead to excessive negative pressure conditions which may cause safety issues with doors and suspended ceilings.

In addition to the above limitations, FMs should be aware that operating large areas of the building under negative pressure conditions for too long can have a negative impact on the indoor environment, especially in areas that experience high outdoor air dew point temperatures. Operating at negative pressure conditions increases the infiltration of unconditioned and unfiltered outdoor air and, in humid environments, this infiltration can lead to surface condensation and damage building materials. For areas with high occupancy rates, recirculating HEPA filtered air units can also be an option. For this option, the HEPA filtered air units can circulate the air which will result in a significant increase in the clean air ventilation rate. Based on the backlog for HEPA filtered air units that occurred in recent months, the largest challenge may be ensuring a sufficient inventory of these units.

Identifying the right solution

Having discovered some of the system limitations in the initial pandemic surge, healthcare facilities are creating safer and more efficient strategies for separating COVID-19 patients from noninfected patients. While some hospitals are examining a redesign of their HVAC system or enhancing HVAC system controls to be able to switch from patient room to negative pressure space at the touch of a button, the cost of implementing these changes may be prohibitive. In comparison, it is generally cost-effective to configure air handling units and spaces for negative pressure operation provided the right partners are brought together in advance.

FMs who have long-standing relationships with HVAC control contractors and testing and balancing contractors may find these conversions can happen rather quickly, especially when contractors are familiar with the building and HVAC equipment. An experienced contractor can help right-size appropriate negative air machines or identify simple maintenance solutions that can help a facility achieve desired goals.

Verify system performance and complete preventive maintenance now

Verifying that HVAC systems are performing as intended and completing preventive maintenance activities will expedite modifications when preparing for the surge. In some cases, contractors found that the existing controls and dampers were either not functioning, or not operating in accordance with the design sequence, turning a simple damper adjustment into repairing and replacing dampers, valves or other components. Taking time to inspect systems for problems today will give FM staff time to acquire materials or equipment on hand in advance of a potential supply chain disruption.

The Centers for Medicare and Medicaid Services (CMS) released an updated list of COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers. The updated list includes a waiver allowing flexibility for many inspections, testing and maintenance (ITM) activities as well as other tasks for Life Safety & Environment of Care during this public health emergency. FMs must think about resuming these tasks after the completion of the public health emergency, and ensuring that the systems are properly working if certain ITM tasks cannot be completed on time.

Putting a plan in place

As many hospital staffs are learning, changing spaces to negative pressure and back again requires careful planning. The best strategy to ensure an effective switch is to develop a Standard Operating Procedure (SOP) for regulating this process. This SOP might include:

• Assessing which spaces will be used to manage testing and surge capacity. The American Society of Health Care Engineering issued does not recommend converting operating rooms, which operate at positive pressure, to negative pressure spaces.

• Identifying triggers for converting spaces to negative pressure.

• Clearly identify steps to modify dampers, adjust fans settings and perform balancing.

• Set requirements for commissioning the system after the switch to verify acceptable negative pressure levels.

• Create steps of functional performance testing to verify the system is performing as expected.

• Perform maintenance activities in support of negative pressure needs. This includes cleaning external components of negative pressure units between patients and changing filters based on the manufacturer’s recommendations (filters do not need to be changed between each patient).

• When converting negative pressure spaces back to their original design, have the contractor test air exchange rates and flow measurements to ensure they meet Facilities Guidelines Institute (FGI) requirements.

Developing this plan will also require open communication with members of the clinical team when prioritizing the location of negative pressure rooms.

Keep communicating

Ultimately, close collaboration with the right partners and open communication channels with the entire FM team will make for a smoother, more rapid conversion to COVID-19 surge spaces.

There are several areas where it is important to establish open communication channels today:

• Talk to the HVAC contractor. By working with an experienced partner who knows a system and facility’s needs, meeting surge needs becomes a far simpler and more effective process.

• Seek third-party engineering and industrial hygiene support. Some solutions are complicated and require expert advice. Be sure to seek advice and support for issues that arise outside of your team’s expertise. The cost of being wrong with these issues can directly impact employee and patient safety.

• Connect with the clinical team. It’s of paramount importance that the clinical team, particularly an infection control practitioner, be involved in assessing surge space and ensuring effectiveness of isolation engineering controls and SOP planning.

• Train FM staff and address their concerns. FM staff may be just as concerned about working in a COVID-19 environment as the clinical staff in these rooms. Continuing education staff can keep them safe, including when and how to use personal protective equipment, and address concerns as they arise. Adopt strategies to clearly communicate infection risks. Clear communication will be critical in gaining staff’s trust and confidence in the importance of routine maintenance tasks in keeping patients safe.

Navigating the challenges ahead

Experience has been a tough teacher for FMs who navigated the 2020 COVID-19 surge. Fortunately, there are lessons learned to make a solid plan for navigating the challenges that lie ahead. A close inspection of the lessons learned will only help speed and streamline processes needed to prepare for what is to come.