Preparing health facilities to cope with ‘COVID-19-normal’

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8 December 2021 | 10 min | Article

By and

As borders open and COVID-19 infections are expected to spread, Aurecon explores the options for our health systems to manage existing and new patients in the new phase of ‘COVID-19-normal’.

Across the globe as vaccinations increase, restrictions ease and borders re-open, many countries are entering a new ‘COVID-19 normality’ as we move from epidemic status to endemic. But as we head into this new phase, our health systems are bracing themselves. With health facilities already under pressure it’s expected they will face additional strain arising from increased COVID-19 hospitalisations as we start to widely embrace the ‘living with COVID-19’ approach.

In general, hospitals have been built without adequate consideration of the management of airborne infection control that COVID-19 has brought to the fore. This now requires a major change in approach to the operation of facilities and the provision of appropriate ventilation and other containment measures to improve infection control resilience.

The situation is moving rapidly, with little time to ponder options and put plans in place. There is an urgent need, as the Australian Medical Association recently reported in its Public Hospital Report Card 2021^[1], to improve services.

The Victorian Government^[2] has already announced an AUD 307 million package to help the state’s hospitals and ambulance services cope with the expected imminent influx.

In an article in the New Zealand Medical Journal, ‘COVID-19: what comes after elimination?’^[3] the authors argue that, going forward, “… increased hospital capacity and better pre-hospital treatment” will be needed to deal with the impacts of moving away from border closures and lockdowns.

Globally, managing health system capacity in the COVID-19 context is a common challenge. Health facilities are racing to create adequate capacity for triage, resuscitation, general ward areas and critical care units (ICU) to support each phase of infection and rehabilitation and ultimately reduce the risk created when hospitalisations exceed current health service capability. It is a challenge being tackled with a range of approaches.

In Hong Kong, ‘second-tier’ isolation beds for recovering patients in a stable condition have been provided in rural areas, to free space for new cases in public hospitals; in Japan and Singapore, due to capacity issues, hospitals only care for the people who are vulnerable or have moderate or severe disease, while people with mild symptoms or who are asymptomatic are supported at home or in lodging facilities.

In England, temporary and modular solutions help to quickly meet additional need, while Spain has adapted other hospital wards and spaces to accommodate patients.

In Australia and New Zealand, fast and adaptable approaches – retrofitting or adapting existing facilities and temporary modular ‘bolt-ons’ – are increasingly being explored to solve current challenges and prepare for what lies ahead.

Adapting or retrofitting existing buildings for safe COVID-19 healthcare

Retrofitting or adapting existing facilities can meet a range of specific needs from triage to critical care, and it’s an approach being undertaken across Australia and New Zealand as health services seek to improve facilities and rapidly increase capacity.

But with ageing health facilities, assets not originally designed for this expected influx, and strict yet evolving regulations for COVID-19 care, there are critical considerations to be made when adopting these solutions.

Possible solutions include negative pressure isolation rooms, improved airflow requirements, access to ventilators with oxygen piped from a medical gas system, and electrical systems with emergency power. Not only must they provide adequate care, but it is imperative they are designed to also prevent and control cross-contamination throughout the facility, at all times.

Designed with pandemic modes built in, this tertiary hospital has an ongoing commitment to maintaining and improving its facilities to boost preparedness.

Control changes to existing wards and transforming an existing operating theatre into a negative pressure operating theatre that uses existing systems and controls, and can revert back to standard operation mode to suit the clinical need has also been implemented.

In just four months, this key tertiary hospital upgraded its infectious diseases ward, converting 15 rooms into negative pressure isolation rooms.

The rooms have been designed to remain in negative pressure in both a nuisance trip and real fire, reducing the chance of infection or cross-contamination throughout the hospital. To further enhance the hospital response, additional modifications are being explored to potentially identify secondary triage, general wards and critical care spaces to suit future demand.

To cater for growing COVID-19 demand, Aurecon is working with this tertiary hospital to deliver a modular facility with N Class rooms, each with an anteroom and ensuite.

The module will be commissioned and ready for patient occupancy by the end of 2021.

Key considerations for adaptation of existing facilities

To achieve successful adaptation or retrofit of existing facilities – which reduces risk, minimises costs, shortens programs, and also meets guidance for COVID-19 care – key factors in planning, design and delivery need to be considered.

Impacts

How will the modifications impact existing operations, including decanting people and equipment, and managing interruptions?

Flexibility

When COVID-19 hospitalisations decrease and demand falls, how can the process be reversed – can it be turned back into its original use, or is it permanent?

Ventilation

Improving clean air delivery rate (CADR) and management of air movement within a hospital in pursuit of infection control is of critical importance and has become even more crucial with the advent of the highly-infectious COVID-19.

With a significant focus on whether existing systems are sharing air with other wards, it is imperative that facilities are adequately equipped with heating, ventilation and air conditioning (HVAC) systems to handle COVID-19 patients. Designs must consider:

Capability of air handling systems
Capability of fitting different filtration systems, exhaust discharges and locations
The risks if air flow is emanating from a COVID-19 ward
The impacts to air return and flow in these rooms and wards in a fire – real or a false alarm (nuisance trip). Preventing air from suddenly flowing to an area of the hospital where it wasn’t expected is absolutely crucial, given our pool of clinical staff is limited, and an erroneous exposure can cause weeks of isolation

Electrical, lighting, medical gas and access

Best practice retrofitting to prepare for the anticipated increase in COVID-19 hospitalisations also considers electrical and lighting, such as body or cardiac protected areas, medical gas (particularly oxygen), ventilators etc.

Also, physical separation between wards and access to door control and security / CCTV is becoming increasingly important to control access in and out of the facility, and also provide a trusted source of traceability for identifying and notifying if testing or quarantine is required.

Alternative delivery methods

With pace being an important factor in coping with ‘COVID-19-normal’, alternative delivery methods, such as ‘design and construct’ delivery, can expedite the retrofit process and reduce construction time compared with traditional construct-only contracts.

With the right teams, risk management and construction method, it is possible to achieve high levels of retrofitting in a short amount of time using a collaborative and risk managed approach.

CASE STUDY

Auckland Hospital and Starship Children’s Hospital

Aurecon is working with Auckland District Health Board to convert existing bed spaces and consultation rooms at Auckland Hospital and Starship Children’s Hospital to negative pressure environments.

Aurecon specialists developed a complex network of mechanical and electrical engineering to operate and manage the negative pressure spaces, including new plant rooms, high efficiency particulate air (HEPA) filtered exhaust systems and specialist monitoring, alarming and control systems. The first package of works was identified, designed, procured, installed, commissioned, and handed over as an accredited negative pressure space for clinical use within just six weeks. Typically, it would take six to nine months to complete.

Much of the conversion works have been focussed in areas of the hospital where patients are critically ill, so mitigating impacts is imperative. Significant effort has been invested in staging the project to minimise disruption, and ongoing communication with clinical staff is essential to ensure works do not impede their operations.

New ‘bolt on’ modular facilities for rapid, additional COVID-19 care capacity

With supply chain capacity and material availability impeding rapid deployment of new builds, accelerated delivery of modular units is proving a viable, popular and fast alternative to urgently expand capacity.

Modularisation can be tailored and scaled for numerous uses: emergency resuscitation and triage, treatment of patients, rehabilitation, and to accommodate departments displaced by COVID-19 care, such as offices, consultation rooms and specialist clinics. Modularity makes it possible to meet these needs outside the existing hospital, with little impact on what’s happening in the hospital. It provides physical separation, reducing risk and the chance of transmission of the virus.

If standardised designs and systems are used, supply chain issues associated with bespoke construction can be minimised. They can be deployed quickly and deliver agility and flexibility to respond to changing circumstances, either at the same location or across a broad geographic area. Modular facilities can be quickly transported and deployed to provide additional capacity in a range of settings and locations – from city, to country, or wherever there is a need.

CASE STUDY

Monash Medical Centre Modular Health Solution, Australia

At Melbourne’s Monash Health, a six-bed resuscitation unit, with negative air flow, nurse station, medication store and dirty/clean utilities, sits adjacent to the existing Monash Medical Centre emergency department. The fully serviced unit was delivered in just three weeks and caters for patients needing ventilation and stabilising before transfer to an inpatient unit or the hospital’s Intensive Care Unit.

Aurecon specialists developed ventilation, electrical, fire protection and hydraulic design solutions to meet the critical clinical and functional requirements of the unit – including containment via negatively pressured ventilation and HEPA filtration of exhaust from each bed bay.

This project was delivered in parallel with the development of guidelines and standards by the Department of Health and Human Services for temporary COVID-19 response facilities, requiring a high degree of flexibility to meet changing requirements. Consideration of the unit’s future use was included in the design planning, and preliminary work has been completed for the Monash Health modular unit to be repurposed into a dialysis unit.

Technically these modular facilities need to be flexible, but also fully fitted with the required clinical services and supporting infrastructure: HVAC, air systems, ventilation, filtration, exhaust discharges, power, medical gas, sanitary, stormwater, chilled water and so on. Whether they have stand-alone services or connect to existing, is a key consideration in the planning and design process. Being stand-alone would improve energy efficiency of the overall facility by reducing demands on existing infrastructure and allows for rapid re-deployment.

Modular units located in close proximity to existing emergency departments provide the ability to connect into existing dependable services infrastructure and enable staff to share support spaces such as change rooms and tea rooms.

Using multiple modules can also provide considerable improvement in operational robustness. For instance, if a modular emergency department triage is identified as an infection site, it can be shut down for deep cleaning without disrupting the operation of the main hospital.

Asking ‘what’s right for the site’ is vital to then determine what other factors are needed to be put in place to ensure the facility works as it should:

Is there an existing hardstand and ability to connect into nearby services?
What are the airflow arrangement requirements?
Will medical gas be connected to the existing facility, or will swap-in bottles be provided?
How will the facility tie into the existing building and infrastructure?
How will the unit be accessed by staff and ambulances?
What are the fire engineering and compliance requirements?
Can the existing site cater for the requirements, or are changes needed to boost existing infrastructure to make it work?

These and other questions must be answered across all technical aspects for the modular facility, to ensure it meets infection control requirements and has the infrastructure to support its effective and safe operation.

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A combined perspective to address the clinical need

Underpinning successful implementation of both modular or retrofit solutions to meet increasing demand for capacity requires a combined team – from clinical, health service, engineering, trades and builders – to connect the dots across planning, design, procurement, construction, risk, and ultimately make decisions at pace, and develop design solutions that respond to the clinical need.

This combined perspective and clinically focussed approach minimises risk, saves time and costs, and ensures the right outcomes are achieved with the best approach that considers all pandemic scenarios and their impacts on ageing infrastructure across the health system.

Closing the gap between need and capacity, quickly

As borders re-open and COVID-19 hospitalisations increase, closing the gap between capacity and need must be achieved quickly. While there is no shortcut, with the right team and the right solution, our health systems can prepare now to meet the challenge of ‘opening up’, while balancing various health concerns.

Being prepared creates confidence for communities that they can get the care they need. It also builds confidence that health services know what’s working, how it works, how it interacts with other facilities, and what can be done to improve that in the best way possible with rising COVID-19 hospitalisations on the horizon.