A common axiom in emergency management is to never let a good disaster go to waste. While COVID certainly taxed hospital facilities' efforts to maintain building homeostasis, it also created momentum and urgency around ventilation that engineering departments can harness to implement mitigations and improve building systems. Now is the time to implement practical mitigations that can elevate patient and staff safety and comfort while optimizing building performance.
The unyielding wrath of COVID catalyzed a full court (ventilation) press. Whole hospital wings were balanced negatively, portable HEPAs were ordered and deployed in mass, and MERV filtration became COVID buzz words not restricted to facility departments. The onus of remembering the fundamentals of ventilation and applying the “do no harm” ethos rests with Facility Directors and Facility Managers, effectively the AHJs (Authority Having Jurisdiction) of their buildings.
Gathering the right SMEs (Subject Matter Experts) to make informed ventilation decisions based on risk, not noise, is critical to maintaining building homeostasis. Developing a “Ventilation Taskforce” comprised of clinical leadership, infection prevention representatives, environment of care stakeholders, and facility departments can drive a collective understanding and confidence in ventilation mitigations based on clear, data-driven criteria. Utilizing the “power in numbers” mantra, this group can quickly become educated allies that can add additional support to capital requests and help calm the unease associated with extended shutdowns/downtimes to address deferred maintenance, design issues, or any number of existing problems.
Remember the Fundamentals
At the onset of COVID, the demand for portable HEPA air filters designed to increase the total number of air exchanges and the creation of “negative pressure” rooms and associated anterooms skyrocketed as hospitals far exceeded their isolation surge capacity. Healthcare facilities spent precious time and money procuring and deploying these units, but until a decision-making matrix is developed that utilizes data such as existing air exchange rate (ACH), shape, size, and current use for the space (location with aerosolizing procedures performed versus an administrative space that does not actively see patients), the demand for portable units will far exceed the supply. Airborne infection isolation rooms (AIIR) maintained with closed doors had long been the gold standard for the treatment of patients with airborne infectious diseases, but these rooms are a luxury in most hospitals and non-existent in clinics and other outpatient facilities.
Pressure requires a relationship. Negative pressure rooms can only be created in relation to their immediate adjacency. The Ventilation Taskforce must consider how changing the way a room is balanced impacts its neighboring locations. Moreover, since “negative pressure” rooms are not considered functional rooms like an AIIR or protective rooms that have strict design and engineering standards (including dedicated exhaust ducted directly outside), they are often part of shared recirculating fan(s). Deploying portable HEPAs haphazardly, without consideration of proper exhaust can effectively over-pressurize a space thereby compromising the integrity of barriers and the original intent of the portable units. Where the air is exhausted is another important consideration with portables.
Shared recirculating fans use indoor air returned and filtered by a shared central fan that redistributes the filtered air back into the environment. Many hospitals started using 100% outside air (OA) during the pandemic to minimize potential cross contamination, which has its own consequences. Most of these units serving existing clinical spaces were never designed for 100% OA. Leaving it at 100% OA indefinitely decreases the ability to control the temperature when the weather deviates below or above 45°-75°, which poses their own serious infection control concerns. While using 100% OA is an option in the CDC’s recommended “layered” approach to physical protection from COVID, adjusting from 100% OA to accommodate seasonal changes in temperature and humidity is just as important as we adjust to coexisting with COVID. Eliminate actions that take away from basic design fundamentals: provide environmental control for comfort, asepsis, odor, and provide air quality that is acceptable to human occupants and that minimizes adverse health effects.
Practical solutions for everyday magic
There are countless practical mitigations that facilities can pursue with the energy and momentum generated by COVID. Now is the time to break out the caulking gun and reseal critical rooms to minimize air leakage and cross-contamination. Additional opportunities include:
- Repair door seals, fix wall and floor penetrations, and perform regular air balance and sensor verifications that includes physical measurements and building automation measurements.
- Write down everything into a plant operation manual, SOP, or other common medium.
- Capitalize on federal grants by fixing and optimizing existing systems and equipment.
- Perform vibration analysis or other predictive or proactive maintenance to ensure equipment reliability when needed.
- Document all engineering control changes in the physical environment, update normal operating and downtime procedures, and share lessons learned to reinforce these improvements. Ensure this information is freely available and stored securely.
- Setup a regulatory dashboard.
- Hire a Building Automation Engineer. Every hospital should have one and a successor.
- Train, train, and retrain staff on aseptic techniques and TAB (test, adjust, balance) principles.
- Dig into engineering controls and make sure zones are all operating correctly and setpoints are properly entered. The Facility Manager/Director must walk through and validate these equipment and system conditions and changes.
- Encourage building operators to become more involved to increase their competencies and promote more effective vigilance of the building systems. Physically walking these systems on a scheduled cadence ensures that the desired outcomes are occurring with purpose!
Leverage the Momentum
Hospital administrators spent the last decade successfully trying to create the same urgency around the elimination of Healthcare-Associated infections (HAIs) that COVID inspired in less than a month. This unparalleled momentum, while certainly exhausting, did more to bridge the physical environment with the clinical environment than ten years of administrative urging. Capitalizing on this momentum to further illuminate strategies to reduce HAIs should be prioritized by facility departments and administration alike. Encouraging humble inquiry and inviting clinical departments to tour the plant from an engineer’s perspective are additional ways to demystify the plant and elevate the elimination of HAIs to the next level. Indeed, simply listening to one’s building engineers is imperative as they are the building system SMEs and know the most pressing capital and operational needs.
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