How will the modifications impact existing operations, including decanting people and equipment, and managing interruptions?
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, to improve services.
The Victorian Government 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?’ 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.
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.
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.
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.
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.
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.
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.
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.
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:
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.
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.
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.
Cameron McLennan is a Building Services Engineer and leads the technical and project delivery focus of the mechanical group in Aurecon’s Queensland business. With a passion for complex projects, he has expertise across the complete life cycle of projects, from strategy through design, delivery and operations. He is currently working with health authorities in Queensland in relation to their COVID response, and has also worked across the industrial, Defence and commercial sectors in Australia, Canada and the Middle East.
Alison Gartrell is the Victorian Health and Education Sector lead with a passion for leading large multidisciplinary teams to deliver significant social infrastructure projects. Alison has been at the forefront of the COVID response in Melbourne, leading ward conversion projects and modular resuscitation units. Alison initiates the development and implementation of robust yet practical project controls and delivery methodology ensuring transparency and strong governance to manage cost, program, contracts and risk. She also has significant experience managing feasibility studies and masterplans for complex health projects and precincts.
Patrick Mok is a Building Services Engineer with extensive engineering design and management experience in a variety of developments and redevelopments in healthcare, industrial, commercial, hotel, institutional and residential sectors. In particular, he is specialised in design and build projects. Patrick has participated in the development of over 20 hospitals, clinics and medical centres and redevelopments, where he was responsible for leading the whole team to ensure quality solutions were delivered.
Matt Capon leads Aurecon’s Buildings team in New Zealand. He has worked on major social infrastructure projects across Europe, New Zealand, Australia and South East Asia managing teams of multi-discipline design engineers, supervising site work, and liaising with clients.
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