The global response to the coronavirus pandemic has shifted from preparedness to response and mitigation. In the U.S., our recent national guidelines are the largest mitigation actions ever enacted in this country. As the virus spreads around the world, each community has responded in their own ways, and some have seen vastly different results. Underpinning every effort, however, is the healthcare system. Resources are being stretched as healthcare services are called upon to the test for disease, contain the outbreak, treat the ill, and administer preventative measures, medicine and vaccines – as they become available.
Given the scale of the coronavirus pandemic, projecting need for and accommodating beds is difficult beyond one to two weeks. With this in mind, our recommended first response is to free up additional capacity within that one- to two-week timeframe using existing resources that can be rapidly modified for quarantine, treatment, and recovery. This can be done with minor modifications to existing hospitals, followed by assembling equipment solutions from non-traditional supply chains (residential or commercial rather than specialist healthcare supply chains) for ad hoc quarantine units in high school gymnasiums or other large assembly facilities.
There are strategies that you can deploy now, using facilities that exist and equipment that is available in your community to fight Coronavirus immediately. We can help.
Preparing a response
Hospitals are not set up to deal with the anticipated surge in patients, meaning ad hoc solutions will be required both to address this outbreak and to allow hospitals to continue treating patients suffering from other ailments..
With coronavirus and other airborne virus outbreaks, there are two types of patient: presumptive cases and known cases. Both groups have different facility requirements and put unique stresses on the hospitals.
There are two critical levels of containment to consider:
- Quarantine: Containing presumptive-case patients from each other and the general population; and
- Isolation: Containing confirmed-case patients from the general population.
Confirmed-case patients can be housed together en masse while presumptive-case patients must be individually quarantined.
For healthcare systems and for our communities in general, finding more available and readily adaptable space becomes a priority – often in non-traditional places. Readily adaptable space can include facilities outside of the traditional healthcare portfolio. The following could become available and be adapted using our quick implementation solutions:
- School closures mean high school or college gymnasiums can offer durable, cleanable surfaces, large open spaces and locker rooms.
- High school or college campuses often have ample open outdoor space to accommodate temporary structures, emergency power and parking
- Hotels and universities/colleges dormitories can be converted using recommended strategies for patient and treatment accommodation.
- Community centers can offer accessible facilities, with durable, clean surfaces, with separate room for those with cognitive vulnerabilities.
To contain this outbreak, and defend against future outbreaks, we must respond in three stages:
- Near-term (7-14 days): to ensure immediate response at the treatment facility level requires nominal readiness based on projections of patient load;
- Mid-term (14-28 days): to ensure large-scale readiness requires short-term response at a larger community level based on projections of patient load;
- Long-term: to ensure appropriate-scale readiness for future outbreaks requires response at the population at large level.
Immediate containment response measures
Adapting existing spaces: immediate response at the treatment facility level to ensure nominal readiness based on near-term projections of patient load.
Hospitals can convert blocks or wings of existing non-critical patient rooms to quarantine or isolation rooms by changing the ventilation and the room entry conditions and standard operating procedures (SOPs). A negative-pressure room is required to isolate a patient who is either suspected of having or who has been diagnosed with an airborne infectious disease so that the number of airborne infectious particles is reduced to prevent cross-infection of other people.
Isolation rooms need to be negatively pressurized to their adjacent, communicating spaces, and they need to have a buffer zone between the isolation room and the corridor outside of the space. Where true anterooms aren’t present to serve as this buffer zone, polyethylene plastic sheeting (Visqueen®) can be hung from the ceiling to create a space where personnel can spray down their personal protective equipment (PPE) with disinfectants such as Lysol® or Virkon®. This allows time for air changes in the anteroom, before removing PPE at the point of exit. While traditional anterooms are positively pressurized to both the corridor and the patient room, this is not required if adequate use of SOPs and disinfectants are employed.
The main patient room can be re-balanced as negatively pressurized if the heating, ventilation and air conditioning (HVAC) system is non-recirculating. Otherwise, windows should be opened or removed, and temporary fans shall be installed at the window, and sealed up with a barrier such as rigid plastic or epoxy-painted plywood.
The window barrier should be sealed around the edges and at the point of ventilation penetration to ensure a tight containment boundary. The use of tell-tales at door undercuts is advised for a quick visual check of directional airflow.
This room setup will work for presumptive- and confirmed-case patients. Room signage, SOPs, and other guidance should be marked on each patient room door as clearly as possible to minimize human error. Training, retraining, and using the pointing-and-calling method for actions as they occur is recommended to eliminate errors as well.
A minimum MERV-16A filter should be applied to the exhaust airstream and shall be operated at a velocity of less than 500 fpm. For the room balance, the ideal differential pressure is between -0.05” and -0.10” w.g. from the corridor to the patient room.
Short-term containment response measures
Short-term response at the community level to ensure large-scale readiness based on mid-term projections of patient load.
As hospitals begin to reach capacity, municipalities should work with healthcare organizations to make a network of support zones that are typically distributed with existing community densities. To further expand your community’s capacity to quarantine presumptive cases, explore opportunities to transition other building types that are similar in structure to a hospital patient wing, including university dormitories or hotels, where similar strategies could be quickly deployed. Additionally, academic health centers pose an opportunity to have nearby healthcare and flex space using large open spaces like gymnasiums and dining halls.
Each location should be setup with check-in, open-space queueing, and triage. From here, presumptive-case patients should be taken into a dedicated isolation bay. Several bays can be co-located in a large area such as a cafeteria or dining hall. Isolation bays can be constructed with PVC plastic frames and polyethylene plastic sheeting (Visqueen®). Confirmed-case patients should be taken into a large isolation suite, such as a gymnasium. Here, the entire space can be open to the patients who are co-located en masse.
Each isolation bay must be negatively pressurized with MERV-16A filtered exhaust that is operated at less than 500 fpm and is not recirculated into any space. Each isolation bay is provided with an ante room for donning and doffing of PPE. The negative pressure of the isolation bay will cause air to cascade from the large open space, through the ante room, and into the isolation bay. A minimum of 500 CFM is recommended for each isolation bay. In large isolation suites, the entire space is conditioned and ventilated without recirculation to maintain a pressurization between -0.05” and -0.10” w.g. from the clean spaces to the isolation suite.
PVC and polyethylene plastic sheeting can be used to create clean corridors between entry and exit points and the locker spaces that are to be used by the healthcare workers. The locker rooms are where the workers can change from street clothes into PPE, and then back into street clothes at the end of the day. No scrubs or PPE should be taken off-site. Healthcare workers should shower before changing into street clothes and leaving the site.
Provide supporting site infrastructure: Emergency power can be provided for critical equipment such as ventilators via a generator or a dedicated uninterruptable power supply (UPS) at each point of use. Waste and materiel flows should be mapped to avoid cross-contamination. Further, care should be taken to use waste bagging and wipe-down sterilization until the waste can be autoclaved or otherwise safely sterilized.
As with the community at large, the criminal justice system will need to find more available and readily adaptable space for treatment options as a priority – often in non-traditional places.
With minor modifications existing justice facilities could be repurposed to provide ad hoc quarantine units in alternate spaces such as day rooms, food service facilities and/or gymnasiums. These can be furnished, according to need, with equipment from non-traditional supply chains (residential or commercial rather than specialist healthcare supply chains), scaling up as required.
The following spaces could be adapted using our quick implementation solutions:
- Gymnasiums, day rooms, classrooms, or food service areas within secure facilities can offer durable, cleanable surfaces and large open spaces; and
- Dormitories and cells can be converted using recommended strategies for patient and treatment accommodation.
The main in-custody patient room can be re-balanced as negatively pressurized if the heating, ventilation and air conditioning (HVAC) system is non-recirculating. Otherwise, windows can be removed, the openings secured, and temporary fans installed. The use of tell-tales at door undercuts is advised for a quick visual check of directional airflow.
This room setup will work for presumptive- and confirmed-case patients. Room signage, SOPs, and other guidance should be marked on each patient area door as clearly as possible to minimize human error. Training, retraining, and using the occupational safety pointing-and-calling method for actions as they occur is also recommended to eliminate errors.
As treatment facilities begin to reach capacity, jurisdictions might consider working with the facility administration and healthcare organizations to create a network of support zones encompassing the detention facility and the wider community. Academic health centers could also be part of this network, with the advantage of having auxiliary healthcare professionals available.
AECOM can help
Each facility is different, so please consider allowing AECOM to answer any questions you might have, and to assist as your partner in immediately addressing your most pressing needs. Our staff of engineering consultants is ready to help and guide you through the process, modifications, SOPs, and start-up.
Distributed across the United States, AECOM’s teams are ready to support your community healthcare needs with the following services:
- Disaster preparedness, response, and recovery planning and strategy development
- Disaster response program management
- Access to specialist expertise to support your in-house teams.
- Communication and outreach
- Solution design, development and delivery
- Operational facility re-programming
- Transportation management to ensure containment during transfer
- Business continuity consulting
- Microgrid design and delivery
- Post-event cleanup and transition consulting
Please contact us to discuss how we can help.