The HILLSIDE - User contributions [en-gb]

Infrastructure Unit System Support

2022-06-17T15:11:23Z

Peta: /* Additional Supporting Documents */

Infrastructure Unit System Support

2022-06-17T15:05:28Z

Peta: /* Document List */

This IUSS Online website was the repository for documents and tools developed under the Infrastructure Unit System Support - IUSS - project, an initiative of the National Department of Health, under the leadership of Dr Massoud Shaker and Mr Ndinannyi Mphaphuli. The purpose of the documents was to provide guidance and improved healthcare infrastructure delivery. The website was discontinued in 2021 and replaced with the Hillside.info wiki.

==Document List==
{
|In-patient services
|Generic room data
|Integrated infrastructure planning
|Laboratories
|Hospital design principles
|Project planning & briefing
|Critical care
|Cost guidelines
|Mortuary
|Materials & finishes
|Procurement liaison
|Obstetrics & gynaecology
|Nursing colleges
|Future healthcare environments
|Commissioning
|Oncology
|Healthcare technology
|Sterile supply
|Clinical training
|Infection prevention & control
|Capacity development
|Waste disposal
|Health informatics
|Regulations
|Diagnostic radiology
|Rehabilitation services
|Sub-acute services
|Surgery
}

==Additional Supporting Documents==
{| class="wikitable"
|'''CLINICAL SERVICES'''
|'''SUPPORT SERVICES'''
|'''HEALTHCARE ENVIRONMENT/ CROSSCUTTING ISSUES'''
|'''PROCUREMENT'''

'''& OPERATION'''
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/64-adult-critical-care-gazetted/file Adult Critical Care]
|[https://www.iussonline.co.za/docman/document/support-services/94-central-sterile-service-department-gazetted/file Central Sterile Service Department]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/87-ibts-for-phc-gazetted/file Building Clinic Facilities with Innovative Building Technologies]
|Detail Estimator for a New Hospital
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/65-adult-inpatent-services-gazetted/file Adult Inpatient Services]
|General hospital support services
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/111-aap-functional-space-neonatal-140425-rev-01/file Generic Room Requirements - Functional space: Neonatal]
|[https://www.iussonline.co.za/docman/document/procurement-and-operation/92-fast-user-manual-gazetted/file Detail Estimator for a New Hospital]
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/66-adult-oncology-gazetted/file Adult Oncology Facilities]
|[https://www.iussonline.co.za/docman/document/support-services/96-health-facility-residential-gazetted/file Health Facility Residential]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/113-ajhc-neonatal-baby-resus-140425-rev-01/file Generic Room Requirements - Functional Space: Neonatal Baby Resuscitation]
|[https://www.iussonline.co.za/docman/document/procurement-and-operation/109-2014-08-26-iuss-briefing-manual-gazetted/file IUSS Health Facility Guides: Briefing Manual]
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/67-adult-physical-rehabilitation-gazetted/file Adult Physical Rehabilitation]
|[https://www.iussonline.co.za/norms-standards/support-services/28-hospital-design-principles-2 Hospital Design Principles]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/110-an-functional-space-theatre-140425-rev-01/file Generic Room Requirements - Functional space: Pre Op]
|[https://www.iussonline.co.za/norms-standards/procurement-and-operation/81-maximum-usable-space-design-musd-estimator Maximum Usable Space Design (MUSD) Estimator (Ungazetted)]
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/68-clinical-and-specialised-diagnostic-laboratories-gazetted/file Clinical and Specialised Diagnostic Laboratories]
|[https://www.iussonline.co.za/docman/document/support-services/98-hospital-mortuary-services-gazetted/file Hospital Mortuary Services]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/114-ak-procedure-room-140425-rev-01/file Generic Room Requirements - Functional space: Procedure Room]
|OoM Estimator for New Clinic Community Day Centre or Community Health Centre
|-
|[https://www.iussonline.co.za/norms-standards/clinical-services/14-facilities-for-surgical-procedures Facilities for Surgical Procedures]
|[https://www.iussonline.co.za/norms-standards/support-services/61-infrastructure-design-for-waste-management-in-healthcare-facilities Infrastructure Design for Waste Management in Healthcare Facilities]
|[https://www.iussonline.co.za/norms-standards/healthcare-environment/48-generic-room-requirements-functional-space-treatment-room Generic Room Requirements - Functional space: Treatment Room]
|OoM Estimator for New Hospitals
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/70-maternity-care-facilities-proposal-gazetted/file Maternity Care Facilities]
|[https://www.iussonline.co.za/docman/document/support-services/100-nursing-colleges-and-student-accommodation-gazetted/file Nursing Education Institutions]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/112-aja-treatment-room-140425-rev-01/file Generic Room Requirements - Functional space: Treatment Room]
|OoM Estimator for Upgrade or Additions to Clinic, Community Day Centre or Community Health Centre
|-
|
|
|[https://www.iussonline.co.za/docman/ungazetted-documents/healthcare-environment-crosscutting-issues-1/126-iuss-healthcare-technology-proposal/file Healthcare Technology Proposal (Ungazetted)]
|OoM Estimator: Upgrade/Additions to Hospitals
|-
|
|
|
|OoM Maintenance Estimator for Clinic. CDC and CHC
|-
|
|
|
|OoM Maintenance Estimator for Hospitals
|-
|
|
|
|[https://www.iussonline.co.za/docman/document/procurement-and-operation/89-space-guidelines-qs-architect-instruction-gazetted/file Space Guidelines QS Architect Instruction]
|}

==Application==
IUSS voluntary standard/ guidance documents have been prepared as national Guidelines, Norms and Standards for the benefit of all South Africans. They are for use by those involved in the procurement, design, management and commissioning of public healthcare infrastructure. Many have been made mandatory via gazette and are clearly marked with this status on the front cover and in footers on each page. IUSS material may also be useful information and reference to private sector healthcare providers.

Use of the guidance does not absolve professional responsibilities of the implementing parties, and it remains incumbent on the relevant authorities and professionals to ensure that these are applied with due diligence, and where appropriate, deviations processes are exercised.

Gazetted guidelines are for public reference information and for application by Provincial Departments of Health in the planning and implementation of public sector health facilities. The gazetted guidelines will be applicable to the planning, design and implementation of all new public-sector building projects (including additions and alterations to existing facilities). Any deviations from the voluntary standards are to be motivated during the Infrastructure Delivery Management Systems (IDMS) gateway approval process. The guidelines should not be seen as necessitating the alteration and upgrading of any existing healthcare facilities.

==Development process==
The development process initiated in 2010 was to consolidate information from a range of sources including local and international literature, expert opinion, practice and expert group workshop into a first-level discussion status document. This was then released for public comment through the project website, as well as national and provincial channels. Feedback and further development were consolidated into a second-level development status document which again was released for comment and rigorous technical review. Further feedback was incorporated into proposal status documents and formally submitted to the National Department of Health. Once signed off, the documents were gazetted.

Documents and tools have been assigned a version number and date. The National Department of Health will establish a Health Infrastructure Norms Advisory Committee, which will be responsible for the periodic review and formal update of documents and tools. Documents and tools should therefore always be retrieved from the website repository www.iussonline.co.za or Department web portal (forthcoming) to ensure that the latest version is being used.

Updating is currently limited to quarterly cost models updates only. Feedback is welcome and updates will be posted if these become available.

==Acknowledgements==

IUSS Norms and Standards were developed with extensive input from numerous individuals and the contributions are appreciated and noted in individual publications.
<gallery>
File:CSIR logo.jpg|Council for Scientific and Industrial Research
</gallery>
[[Category:IUSS]]

Infrastructure Unit System Support

2022-06-17T15:04:59Z

Peta: /* Document List */

This IUSS Online website was the repository for documents and tools developed under the Infrastructure Unit System Support - IUSS - project, an initiative of the National Department of Health, under the leadership of Dr Massoud Shaker and Mr Ndinannyi Mphaphuli. The purpose of the documents was to provide guidance and improved healthcare infrastructure delivery. The website was discontinued in 2021 and replaced with the Hillside.info wiki.

==Document List==
{| class="wikitable"
|In-patient services
|Generic room data
|Integrated infrastructure planning
|Laboratories
|Hospital design principles
|Project planning & briefing
|Critical care
|Cost guidelines
|Mortuary
|Materials & finishes
|Procurement liaison
|Obstetrics & gynaecology
|Nursing colleges
|Future healthcare environments
|Commissioning
|Oncology
|Healthcare technology
|Sterile supply
|Clinical training
|Infection prevention & control
|Capacity development
|Waste disposal
|Health informatics
|Regulations
|Diagnostic radiology
|Rehabilitation services
|Sub-acute services
|Surgery
}

==Additional Supporting Documents==
{| class="wikitable"
|'''CLINICAL SERVICES'''
|'''SUPPORT SERVICES'''
|'''HEALTHCARE ENVIRONMENT/ CROSSCUTTING ISSUES'''
|'''PROCUREMENT'''

'''& OPERATION'''
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/64-adult-critical-care-gazetted/file Adult Critical Care]
|[https://www.iussonline.co.za/docman/document/support-services/94-central-sterile-service-department-gazetted/file Central Sterile Service Department]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/87-ibts-for-phc-gazetted/file Building Clinic Facilities with Innovative Building Technologies]
|Detail Estimator for a New Hospital
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/65-adult-inpatent-services-gazetted/file Adult Inpatient Services]
|General hospital support services
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/111-aap-functional-space-neonatal-140425-rev-01/file Generic Room Requirements - Functional space: Neonatal]
|[https://www.iussonline.co.za/docman/document/procurement-and-operation/92-fast-user-manual-gazetted/file Detail Estimator for a New Hospital]
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/66-adult-oncology-gazetted/file Adult Oncology Facilities]
|[https://www.iussonline.co.za/docman/document/support-services/96-health-facility-residential-gazetted/file Health Facility Residential]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/113-ajhc-neonatal-baby-resus-140425-rev-01/file Generic Room Requirements - Functional Space: Neonatal Baby Resuscitation]
|[https://www.iussonline.co.za/docman/document/procurement-and-operation/109-2014-08-26-iuss-briefing-manual-gazetted/file IUSS Health Facility Guides: Briefing Manual]
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/67-adult-physical-rehabilitation-gazetted/file Adult Physical Rehabilitation]
|[https://www.iussonline.co.za/norms-standards/support-services/28-hospital-design-principles-2 Hospital Design Principles]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/110-an-functional-space-theatre-140425-rev-01/file Generic Room Requirements - Functional space: Pre Op]
|[https://www.iussonline.co.za/norms-standards/procurement-and-operation/81-maximum-usable-space-design-musd-estimator Maximum Usable Space Design (MUSD) Estimator (Ungazetted)]
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/68-clinical-and-specialised-diagnostic-laboratories-gazetted/file Clinical and Specialised Diagnostic Laboratories]
|[https://www.iussonline.co.za/docman/document/support-services/98-hospital-mortuary-services-gazetted/file Hospital Mortuary Services]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/114-ak-procedure-room-140425-rev-01/file Generic Room Requirements - Functional space: Procedure Room]
|OoM Estimator for New Clinic Community Day Centre or Community Health Centre
|-
|[https://www.iussonline.co.za/norms-standards/clinical-services/14-facilities-for-surgical-procedures Facilities for Surgical Procedures]
|[https://www.iussonline.co.za/norms-standards/support-services/61-infrastructure-design-for-waste-management-in-healthcare-facilities Infrastructure Design for Waste Management in Healthcare Facilities]
|[https://www.iussonline.co.za/norms-standards/healthcare-environment/48-generic-room-requirements-functional-space-treatment-room Generic Room Requirements - Functional space: Treatment Room]
|OoM Estimator for New Hospitals
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/70-maternity-care-facilities-proposal-gazetted/file Maternity Care Facilities]
|[https://www.iussonline.co.za/docman/document/support-services/100-nursing-colleges-and-student-accommodation-gazetted/file Nursing Education Institutions]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/112-aja-treatment-room-140425-rev-01/file Generic Room Requirements - Functional space: Treatment Room]
|OoM Estimator for Upgrade or Additions to Clinic, Community Day Centre or Community Health Centre
|-
|
|
|[https://www.iussonline.co.za/docman/ungazetted-documents/healthcare-environment-crosscutting-issues-1/126-iuss-healthcare-technology-proposal/file Healthcare Technology Proposal (Ungazetted)]
|OoM Estimator: Upgrade/Additions to Hospitals
|-
|
|
|
|OoM Maintenance Estimator for Clinic. CDC and CHC
|-
|
|
|
|OoM Maintenance Estimator for Hospitals
|-
|
|
|
|[https://www.iussonline.co.za/docman/document/procurement-and-operation/89-space-guidelines-qs-architect-instruction-gazetted/file Space Guidelines QS Architect Instruction]
|}

==Application==
IUSS voluntary standard/ guidance documents have been prepared as national Guidelines, Norms and Standards for the benefit of all South Africans. They are for use by those involved in the procurement, design, management and commissioning of public healthcare infrastructure. Many have been made mandatory via gazette and are clearly marked with this status on the front cover and in footers on each page. IUSS material may also be useful information and reference to private sector healthcare providers.

Use of the guidance does not absolve professional responsibilities of the implementing parties, and it remains incumbent on the relevant authorities and professionals to ensure that these are applied with due diligence, and where appropriate, deviations processes are exercised.

Gazetted guidelines are for public reference information and for application by Provincial Departments of Health in the planning and implementation of public sector health facilities. The gazetted guidelines will be applicable to the planning, design and implementation of all new public-sector building projects (including additions and alterations to existing facilities). Any deviations from the voluntary standards are to be motivated during the Infrastructure Delivery Management Systems (IDMS) gateway approval process. The guidelines should not be seen as necessitating the alteration and upgrading of any existing healthcare facilities.

==Development process==
The development process initiated in 2010 was to consolidate information from a range of sources including local and international literature, expert opinion, practice and expert group workshop into a first-level discussion status document. This was then released for public comment through the project website, as well as national and provincial channels. Feedback and further development were consolidated into a second-level development status document which again was released for comment and rigorous technical review. Further feedback was incorporated into proposal status documents and formally submitted to the National Department of Health. Once signed off, the documents were gazetted.

Documents and tools have been assigned a version number and date. The National Department of Health will establish a Health Infrastructure Norms Advisory Committee, which will be responsible for the periodic review and formal update of documents and tools. Documents and tools should therefore always be retrieved from the website repository www.iussonline.co.za or Department web portal (forthcoming) to ensure that the latest version is being used.

Updating is currently limited to quarterly cost models updates only. Feedback is welcome and updates will be posted if these become available.

==Acknowledgements==

IUSS Norms and Standards were developed with extensive input from numerous individuals and the contributions are appreciated and noted in individual publications.
<gallery>
File:CSIR logo.jpg|Council for Scientific and Industrial Research
</gallery>
[[Category:IUSS]]

Infrastructure Unit System Support

2022-06-17T15:00:54Z

Peta: /* About IUSS */

This IUSS Online website was the repository for documents and tools developed under the Infrastructure Unit System Support - IUSS - project, an initiative of the National Department of Health, under the leadership of Dr Massoud Shaker and Mr Ndinannyi Mphaphuli. The purpose of the documents was to provide guidance and improved healthcare infrastructure delivery. The website was discontinued in 2021 and replaced with the Hillside.info wiki.

==Document List==
{| class="wikitable"
|'''CLINICAL SERVICES'''
|'''SUPPORT SERVICES'''
|'''HEALTHCARE ENVIRONMENT/ CROSSCUTTING ISSUES'''
|'''PROCUREMENT'''

'''& OPERATION'''
|-
|In-patient services
|[https://www.iussonline.co.za/docman/document/support-services/115-admin-and-related-services-gazetted/file Administration & Related Services]
|Generic room data
|Integrated infrastructure planning
|-
|Laboratories
|[https://www.iussonline.co.za/docman/document/support-services/95-general-hospital-support-services-gazetted/file General hospital support services]
|Hospital design principles
|Project planning & briefing
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/71-mental-health-gazetted/file Mental Health]
|[https://www.iussonline.co.za/docman/document/support-services/93-catering-services-for-hospitals-gazetted/file Catering Services for Hospitals]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file Building Engineering Services]
|[https://www.iussonline.co.za/docman/document/procurement-and-operation/89-space-guidelines-qs-architect-instruction-gazetted/file Space Guidelines QS Architect Instruction]
|-
|Critical care
|[https://www.iussonline.co.za/docman/document/support-services/99-laundry-and-linen-department-gazetted/file Laundry and Linen Department]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/78-environment-and-sustainability-gazetted/file Environment and Sustainability]
|Cost guidelines
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/104-emergency-centre-gazetted/file Emergency Centres]
|Mortuary
|Materials & finishes
|Procurement liaison
|-
|Obstetrics & gynaecology
|Nursing colleges
|Future healthcare environments
|Commissioning
|-
|Oncology
|[https://www.iussonline.co.za/docman/document/support-services/96-health-facility-residential-gazetted/file Health Facility Residential]
|Healthcare technology
|[https://www.iussonline.co.za/docman/document/procurement-and-operation/88-maintenance-gazetted/file Maintenance]
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/73-outpatients-gazetted/file Outpatient Facilities]
|Sterile supply
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/79-inclusive-environments-gazetted/file Inclusive Environments]
|[https://www.iussonline.co.za/docman/document/procurement-and-operation/86-decommissioning-gazetted/file Decommissioning of Healthcare Infrastructure and Healthcare Technology]
|-
|[https://www.iussonline.co.za/norms-standards/clinical-services/19-paediatrics-and-neonatal-facilities Paediatrics and Neonatal Facilities]
|Clinical training
|Infection prevention & control
|Capacity development
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/75-pharmacy-gazetted/file Pharmacy]
|Waste disposal
|Health informatics
|
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/76-phc-gazetted/file Primary Healthcare Facility]
|
|Regulations
|
|-
|Diagnostic radiology
|
|
|
|-
|Rehabilitation services
|
|
|
|-
|Sub-acute services
|
|
|
|-
|Surgery
|
|
|
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/77-tb-services-proposal-gazetted/file TB]
|
|
|
|}

==Additional Supporting Documents==
{| class="wikitable"
|'''CLINICAL SERVICES'''
|'''SUPPORT SERVICES'''
|'''HEALTHCARE ENVIRONMENT/ CROSSCUTTING ISSUES'''
|'''PROCUREMENT'''

'''& OPERATION'''
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/64-adult-critical-care-gazetted/file Adult Critical Care]
|[https://www.iussonline.co.za/docman/document/support-services/94-central-sterile-service-department-gazetted/file Central Sterile Service Department]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/87-ibts-for-phc-gazetted/file Building Clinic Facilities with Innovative Building Technologies]
|Detail Estimator for a New Hospital
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/65-adult-inpatent-services-gazetted/file Adult Inpatient Services]
|General hospital support services
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/111-aap-functional-space-neonatal-140425-rev-01/file Generic Room Requirements - Functional space: Neonatal]
|[https://www.iussonline.co.za/docman/document/procurement-and-operation/92-fast-user-manual-gazetted/file Detail Estimator for a New Hospital]
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/66-adult-oncology-gazetted/file Adult Oncology Facilities]
|[https://www.iussonline.co.za/docman/document/support-services/96-health-facility-residential-gazetted/file Health Facility Residential]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/113-ajhc-neonatal-baby-resus-140425-rev-01/file Generic Room Requirements - Functional Space: Neonatal Baby Resuscitation]
|[https://www.iussonline.co.za/docman/document/procurement-and-operation/109-2014-08-26-iuss-briefing-manual-gazetted/file IUSS Health Facility Guides: Briefing Manual]
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/67-adult-physical-rehabilitation-gazetted/file Adult Physical Rehabilitation]
|[https://www.iussonline.co.za/norms-standards/support-services/28-hospital-design-principles-2 Hospital Design Principles]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/110-an-functional-space-theatre-140425-rev-01/file Generic Room Requirements - Functional space: Pre Op]
|[https://www.iussonline.co.za/norms-standards/procurement-and-operation/81-maximum-usable-space-design-musd-estimator Maximum Usable Space Design (MUSD) Estimator (Ungazetted)]
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/68-clinical-and-specialised-diagnostic-laboratories-gazetted/file Clinical and Specialised Diagnostic Laboratories]
|[https://www.iussonline.co.za/docman/document/support-services/98-hospital-mortuary-services-gazetted/file Hospital Mortuary Services]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/114-ak-procedure-room-140425-rev-01/file Generic Room Requirements - Functional space: Procedure Room]
|OoM Estimator for New Clinic Community Day Centre or Community Health Centre
|-
|[https://www.iussonline.co.za/norms-standards/clinical-services/14-facilities-for-surgical-procedures Facilities for Surgical Procedures]
|[https://www.iussonline.co.za/norms-standards/support-services/61-infrastructure-design-for-waste-management-in-healthcare-facilities Infrastructure Design for Waste Management in Healthcare Facilities]
|[https://www.iussonline.co.za/norms-standards/healthcare-environment/48-generic-room-requirements-functional-space-treatment-room Generic Room Requirements - Functional space: Treatment Room]
|OoM Estimator for New Hospitals
|-
|[https://www.iussonline.co.za/docman/document/clinical-services/70-maternity-care-facilities-proposal-gazetted/file Maternity Care Facilities]
|[https://www.iussonline.co.za/docman/document/support-services/100-nursing-colleges-and-student-accommodation-gazetted/file Nursing Education Institutions]
|[https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/112-aja-treatment-room-140425-rev-01/file Generic Room Requirements - Functional space: Treatment Room]
|OoM Estimator for Upgrade or Additions to Clinic, Community Day Centre or Community Health Centre
|-
|
|
|[https://www.iussonline.co.za/docman/ungazetted-documents/healthcare-environment-crosscutting-issues-1/126-iuss-healthcare-technology-proposal/file Healthcare Technology Proposal (Ungazetted)]
|OoM Estimator: Upgrade/Additions to Hospitals
|-
|
|
|
|OoM Maintenance Estimator for Clinic. CDC and CHC
|-
|
|
|
|OoM Maintenance Estimator for Hospitals
|-
|
|
|
|[https://www.iussonline.co.za/docman/document/procurement-and-operation/89-space-guidelines-qs-architect-instruction-gazetted/file Space Guidelines QS Architect Instruction]
|}

==Application==
IUSS voluntary standard/ guidance documents have been prepared as national Guidelines, Norms and Standards for the benefit of all South Africans. They are for use by those involved in the procurement, design, management and commissioning of public healthcare infrastructure. Many have been made mandatory via gazette and are clearly marked with this status on the front cover and in footers on each page. IUSS material may also be useful information and reference to private sector healthcare providers.

Use of the guidance does not absolve professional responsibilities of the implementing parties, and it remains incumbent on the relevant authorities and professionals to ensure that these are applied with due diligence, and where appropriate, deviations processes are exercised.

Gazetted guidelines are for public reference information and for application by Provincial Departments of Health in the planning and implementation of public sector health facilities. The gazetted guidelines will be applicable to the planning, design and implementation of all new public-sector building projects (including additions and alterations to existing facilities). Any deviations from the voluntary standards are to be motivated during the Infrastructure Delivery Management Systems (IDMS) gateway approval process. The guidelines should not be seen as necessitating the alteration and upgrading of any existing healthcare facilities.

==Development process==
The development process initiated in 2010 was to consolidate information from a range of sources including local and international literature, expert opinion, practice and expert group workshop into a first-level discussion status document. This was then released for public comment through the project website, as well as national and provincial channels. Feedback and further development were consolidated into a second-level development status document which again was released for comment and rigorous technical review. Further feedback was incorporated into proposal status documents and formally submitted to the National Department of Health. Once signed off, the documents were gazetted.

Documents and tools have been assigned a version number and date. The National Department of Health will establish a Health Infrastructure Norms Advisory Committee, which will be responsible for the periodic review and formal update of documents and tools. Documents and tools should therefore always be retrieved from the website repository www.iussonline.co.za or Department web portal (forthcoming) to ensure that the latest version is being used.

Updating is currently limited to quarterly cost models updates only. Feedback is welcome and updates will be posted if these become available.

==Acknowledgements==

IUSS Norms and Standards were developed with extensive input from numerous individuals and the contributions are appreciated and noted in individual publications.
<gallery>
File:CSIR logo.jpg|Council for Scientific and Industrial Research
</gallery>
[[Category:IUSS]]

Building Engineering Services

2020-08-20T13:25:35Z

Peta: /* Planning for Retrofitting& Decommissioning */

{{Cleanup}}{{Expand}}

=='''POLICY AND SERVICE CONTEXT'''==
===Overview===
Many of the Building Engineering Services of a health facility have specialised needs within the context of healthcare provision and infection prevention and control. Specialist needs may include a combination of hygiene, redundancy and contamination-control requirements over and above the normal best engineering practice.

The Building Engineering Services dealt with in this document include: ventilation systems, wet services, gas and vacuum services, electrical services and electronic services.
The primary function of this document is to provide terms of reference to designers who are contacted to develop building engineering services systems. This document does not serve as a principal facility planning guide but as a best-practice guide within any planned level of healthcare service.
“This document describes engineering design, installation and commissioning principles in terms of current specialist clinical, contamination control and maintenance requirements“

===Policy and Service Context===
'''Context'''
This document serves as guidance in the development of all levels of the healthcare facility. Certain sections may not be applicable to all considered levels of facility although, where a certain engineering service is supplied, that service shall be developed in accordance with the guiding principles contained herein.
'''Design principles'''
This document will detail design principles within the scope of services described in the Engineering Council of South Africa’s gazetted Guideline scope of services and tariff of fees in terms of the Engineering Professions Act (46 of 200). This document will also describe design, installation and commissioning principles in terms of current specialist clinical, contamination-control and maintenance requirements.
While this document details design requirements and acceptance criteria which have an impact on clinical services, these requirements are prescribed within the framework of the entire IUSS set of guidance documents, and cannot be viewed in isolation. The following documents should be complied with, together with this document:
Within the South African healthcare context, many clinical and administrative zones may be subject to infection prevention and control measures with particular consideration for airborne contamination control.

===Service Context===
'''Levels of care'''

#“Levels of Care” is discussed in detail in the Project Planning and Briefing document. The Building Engineering Services document does not prescribe levels of care within the healthcare system and does not delineate the application of technology within these levels. It intends only to describe the building engineering services and technical aspects that should be considered from the concept development to the closeout and handover stages of the project. It is not incumbent on the engineer to prescribe appropriate levels of care and this subject is therefore not addressed herein. The allocation of appropriate technologies and services within the prescribed levels of care is a function of the engineer during the facility-planning stage as described by this document.
#In this document, where three distinct options are made describing system quantities or capacities, these are to be interpreted as the minimum acceptable standard, recommended best practice, and maximum practical limit respectively. Where only two options are given, these are to be interpreted as the minimum standard and best practice respectively. Where only one option is given, this is to be interpreted as the minimum acceptable standard. The reader is cautioned not to interpret these capacity standards as levels of care.
<gallery mode="packed" heights="600">
File:King George V (KZN 2013).jpg|King George V (KZN 2013)
</gallery>

=='''PLANNING AND DESIGN'''==
===Overview===
The national and provincial service and policy context should be the basic determinant of planning and design principles in the public sector
The national and provincial service and policy context (Part A of this document) is the basic determinant of planning and design principles in the public sector. In the private sector, planning and design will have determinants as defined by the service provider, within certain minimum prescribed limits. Part B describes the scope of planning and design guidance, design considerations and functional relationships between engineering systems. These principles are subsequently developed into a series of Design Specifications (Part C), Commissioning, Handover and Decommissioning (Part D) including some case studies (Part E). Parts C, D and E are intended to demonstrate how the principles prescribed in Part B should be applied. Parts C and D, if used directly, are deemed to satisfy the principles developed in Part B, but are not the only acceptable solutions. Case studies (Part E) are for illustrative purposes, to demonstrate worked solutions and should not be adopted without appropriate contextual adaptation
===Stages of design and implementation===

#It is critical that building engineering services professionals involve themselves in the early stages of a project’s initial planning, studies, investigations and assessments. Exclusion or late inclusion of an engineering team from the planning stages of a multi-disciplinary construction project presents a considerable risk of resulting, not in savings, but fruitless expenditure, design delays and ultimately compromises in the functional and build quality of the product.
#The scoping and broad coordination of services is invaluable during concept development, and the value-added through the early inclusion of building services professionals is frequently underestimated.
#Briefing authorities or developers are therefore encouraged to ensure that the client’s representative consults with a team of engineering professionals during the earliest project-planning stages. The deliverables of the concept and viability study stages should, therefore, include the following:
##Summaries of collated information
##Reports on technical feasibility, benefits and risks
##Reports on regulatory compliance issues
##Reports on financial feasibility and risks
##List of consents and approvals required
##Schedule of additional surveys, tests, analyses, studies and investigations.
#'''The Guideline Scope of Services and Tariff of Fees''' for Persons Registered in Terms of the Engineering Profession Act 46 of 2000 (2012) defines the following as within the [http://www.ecsa.co.za/documents/EngProfAct46_2000.pdf Normal Scope of Professional Services].
##'''INCEPTION'''
###At the inception stage, the client’s requirements and needs are established. The project brief is established and the professional team is appointed. The professional team should contribute towards developing the project brief and concluding the terms of its appointment. Here the professional team should advise on criteria that could significantly impact on the project life cycle cost.
##'''CONCEPT AND VIABILITY STUDY'''
###At the Concept and Viability study stage, the preliminary design details and cost estimates should be finalised. This should be concluded in accordance with the project brief.
###A Preliminary design report would include the:
####Concept design
####Process design
####Schedule of design assumptions, required surveys, tests, reports and investigations
####Preliminary design details
####Installation and life cycle cost estimates
##'''DESIGN DEVELOPMENT / DETAIL DESIGN'''
###During design development the design team will further develop the concept to realise the following:
####Finalised design
####Detail specification outline
####Financial plan
####Project programme.
##DOCUMENTATION AND PROCUREMENT
###This stage is often combined with the design development stage.
###Its deliverables include:
####Procurement and construction documentation and specifications
####Application of timeous procurement strategies appropriate for the project
####Assisting in the tender evaluation of detailed services and samples for compliance with the design intent.
##'''CONTRACT ADMINISTRATION AND INSPECTION'''
###This stage includes the management and administration of the construction contracts and works to facilitate practical completion in accordance with the design intent.
##'''CLOSEOUT'''
###Closeout deliverables include:
####Final works-completion lists
####Financial reports and final accounts
####Facilitation in development of Operation and Maintenance Manuals (O&Ms), warranties and guarantees.
####As-built drawings

===Design Questions===
In order for the engineer to satisfactorily fulfil the user’s requirements, the following list of questions should be asked, answered and understood by the professional services team.
“Engineers responsible for the design of environmental control systems require guidelines and standards, in order to derive at and to specify appropriate solutions to the problem of building related illness (BRI) in occupied spaces.” -Dr S. A Parsons 2002

#Is the building service required, and why?
#What options are available?
#What is the service’s required performance?
#What is the service’s expected lifespan?
#What is needed in terms of energy management?
#What are the expected service consumption rates?
#What are the expected occupancy profiles per planning unit, considering:
##Patient and staff numbers?
##Peak occupancy times?
##Airborne infection risk profile?
##Seasonal occupancy profiles?
#What are service distribution constraints, considering:
##Location
##Space?
##Fire protection and regulations?
##Services coordination?
##Access for maintenance and operations?
##Repair replacement and refurbishment?
#What are the minimum component/system requirements?
#What are the specific requirements regarding functional controls?
#What are validation and testing requirements
#What are the Maintenance and operational requirements?
#Commissioning and handover requirements
#Special requirements for test and balance documents and certificates

===Design considerations===
'''Deep buildings'''

Deep buildings inevitably result in some measure of ventilation being required within the core areas. Where deep buildings cannot be avoided, the extent of building ventilation can be minimised by planning the deep-core areas as those that require specialist ventilation systems and which could not be served by natural ventilation.

'''Plant and plant room size and location'''

Noisy and vibrating equipment shall not be placed near, above or below sensitive areas such as operating rooms and ICUs. They shall be designed and located so as to give sufficient reduction in noise and vibration.

Plant rooms shall be designed such that there is safe access to equipment for maintenance and repair activities.
Plant rooms shall be located away from possible heat and contamination sources.

Plant rooms shall be located in an accessible area which is secured from unauthorized entry

Where plant room equipment presents a potential source of airborne contamination (e.g. Legionella and vacuum exhaust) the location of the plant room shall be such that contaminated air is not carried into occupied spaces and air inlets.

===Life cycle cost determination===
When planning and designing building engineering services, the engineer shall take cognisance of the service context within which the facility is placed. As part of the financial plan, outlined in the concept and viability study stage, the engineer will assist in developing the facility’s life cycle cost by giving input into the life cycle cost estimates for the services within the engineer’s responsibility. This financial plan shall be finalised as a deliverable of the detail design stage.

Environmental life cycle planning is a critical element of the life cycle planning but should be considered as a service additional to the scope of the normal prescribed services.

===Site-survey requirements===
In order for the engineer to plan adequately, a detailed site survey will need to be conducted to present essential planning information. These factors need to be weighed against the level of service to be provided.

The National Department of Public Works has developed a comprehensive site-survey model for the completion of this task (Citation needed). The following list summarises the information that needs to be developed.

#Geotechnical considerations
#Availability, quantity and quality of mobile phone reception
#Availability, quantity and quality of services such as:
##Electricity
##Water supply
##Drainage conditions
##Gas
##Land and air transport
##Outsourced laundry and catering services
##Proximity to additional social services

===Maintenance Considerations===
Maintenance failures within the building services of the healthcare environment have the potential for severe consequences. Services should be designed with this in mind.

The design should consider the financial and environmental impact of disposable and reusable components within the planned maintenance regime. Reporting on the financial aspects of the life cycle plan is required within the normal scope of services of the planning and design project stages.

In the development of healthcare building engineering services the designer should consider the following maintenance challenges when designing systems and planning maintenance regimes:

#Where highly specialised services are installed in remote areas, it becomes difficult to source the requisite level of technical skills and, as a result, either maintenance costs rise or the serviceable life of these systems is decreased.
#The availability of spares and contracted technical services becomes problematic in remote locations and this leads to difficulties with unscheduled maintenance and extended callout response times.
#Routine and unscheduled maintenance may need to be performed with a system in operation, with minimal down-time. This should be considered when planning levels of redundancy.
#Routine and unscheduled maintenance should not have a negative impact of the service levels of healthcare. Where IPC and cross-infection risks are high, systems should be designed such that the maintenance staff can complete their work without affecting staff or patient safety.
#For further guidance on health-facility maintenance, the IUSS Health Facilities Maintenance guidance document should be referred to.

===Planning for Retrofitting & Decommissioning===
While engineering systems may have a functional life of 20 to 25 years, healthcare buildings could have a life of 50 years. It is therefore likely that engineering services would need to be decommissioned, retrofitted, and replaced at least once during the life of a building, and these interventions should be planned for.

Projects with a retrofitting element shall include for the formal decommissioning of equipment or services which become redundant or obsolete as a result of the retrofitting project or can be conveniently decommissioned within the project. Decommissioning of any assets shall be undertaken in accordance with the Public Finance Management Act 1 of 1999, the Generally Accepted Accounting Practice, the Companies Act of 2006 and principles of good corporate governance. 

When planning for retrofitting and decommissioning, consideration should be given to the following aspects:

#Development and implementation of a risk assessment and hazard control plan.
#Identification of clinician and IPC manager with authority to approve or halt construction activities under defined conditions.
#Power requirements for future expansions and installations.
#Emerging healthcare technologies.
#Space for removal and refitting of equipment.
#Materials of construction for recycling potential and disposal.
#Toxicity and environmental impact of gases, paints and polymers.
#Specific healthcare services risks (IPC, etc).
#Occupational Health and Safety Regulations and requirements. 

A risk assessment shall consider the following aspects:

#Identification of occupancy groups which are susceptible to risks.
#Identification of building services, such as ventilation, in the proximity of the construction activity and the potential impact on function. Specific consideration should be given to specialist ventilation systems.
#Need for supplementary protection or support systems for building services.
#Impact on fire-protection and -response systems, and action plans.
#Impact of noise and vibration on occupants and equipment. 

Opportunistic environmental or airborne microorganisms and allergens, which are liberated or distributed during retrofitting and decommissioning activities, can present a significant hazard to patients and employees unusually at risk. Where the environmental and risk assessments identify the need for intervention or mitigating controls, the following shall be considered:

#Establishment of rigid non-permeable barriers between patients or staff and construction activities during construction, with the inclusion of appropriate “airlocks” where traffic between occupied and construction areas is required.
#Increased ventilation rates and ventilation efficiency to areas at risk.
#Extraction and filtration systems serving the construction area. Where there is a chance of re-entrainment of diluted exhausted air, a minimum of an EN779-F9 filter should be installed as the final filtration stage. Where air is actively re-circulated it should be filtered with at least an EN1822-H13 final filter.
#Establishment of a protective pressure cascade or airflow direction between zones. 

For further guidance on the decommissioning of health facilities, the [[Decommissioning and Disposal of Health Facilities and Health Technology|Health Decommissioning and Disposal of Health Facilities and Health Technology]] guidance document should be referred to.

===Sustainability & Environmental Measures===
====Design Life cycle====

Sustainability in designs for new health facilities can be addressed through the following steps:

#'''Target setting:''' Challenging but realistic sustainability targets should be set for the building and agreed with all of the key stakeholders of the project, including the design team, the facilities manager and the funder or owner of the building. Targets should take into account government policy and strategies, as well as local and international best practice.
#'''Design principles:''' Strategies and design principles required to achieve these sustainability objectives should be understood and established from the outset. For instance, energy targets may require passive environmental control strategies to be well understood and established from the outset. These strategies and their implications can be understood through an analysis of best-practice examples and precedents.
#'''Integrated design:''' Once targets and design principles have been established, an integrated design process should be used to ensure that all aspects of the building work together to achieve the required performance. This requires different disciplines to work closely together.
#'''Testing:''' Throughout the design process, checks should be carried out to ensure that the targets set will be achieved. This can be done through calculations, modelling and analysis which assesses performance against targets set. Where aspects of the design are found not to meet targets, a re-evaluation of the design should be carried out and, in an iterative and integrated way, improved to ensure that the performance achieves, or surpasses, targets set.
#'''Detailed design and implementation:''' It is important to ensure that the design principles set out are carried out in detail, or this may affect operational performance. This includes, for instance, seemingly insignificant details such as appropriate locations for switches, labels and instructions.
#'''Handover:''' On completion, effective processes should be followed to ensure that design intentions are carried through into building operation. This includes effective commissioning, handover and training processes which ensure that designers, subcontractors and suppliers transfer knowledge and skills to facilities managers to ensure effective management of the building.

Refer to [[Sustainability|Sustainability Guide]] for further information on sustainability.

=='''DESIGN SPECIFICATIONS'''==
===Design considerations===
Best engineering practices for the design, specification, testing and management of wet services, vacuum, medical gases, building electrical, electronic, and lighting and ventilation systems are contained in this guide. This guide also defines applicable local and international informative standards and describes regulatory aspects for consideration.

===Heating ventilation and air-conditioning===
=====Airborne-precaution risk classification for healthcare zones=====
{| class="wikitable"
|+{{APR Ventilation Risk Matrix}}'''Building Ventilation for Airborne IPC'''
|-

| colspan="2" rowspan="2" style="background-color:#c2d69b " |
! colspan="3" style="background-color:#c2d69b " |'''Patient/Staff Susceptibility to Infection'''**
|-
| style="background-color:#c2d69b " |'''Low'''
| style="background-color:#c2d69b " |'''Moderate'''
| style="background-color:#c2d69b " |'''High'''
|-

| rowspan="3" style="background-color:#c2d69b " |'''Potential for cross infection'''*
| style="background-color:#c2d69b " |'''High'''
||
*Administrative controls
*Controlled access
*Negative pressure
*Fresh air (FA) supply >80L/s per person
||
*Administrative controls
*Controlled access
*Negative pressure
*FA supply >80L/s per person
||
*Administrative controls
*Controlled access
*Negative pressure room with overpressure airlocks
*Clean air supply >20AC/h and 80L/s per person
|-

| style="background-color:#c2d69b " |'''Moderate'''
||
*Administrative controls
*Fresh air supply >60L/s per person
||
*Administrative controls
*Controlled access
*FA supply >60L/s per person
||
*Administrative controls
*Clean air supply >60L/s per person and 20 AC/h
*Overpressure airlocks
|-

| style="background-color:#c2d69b " |'''Low'''
||
*No additional requirements
||
*Administrative controls
*FA supply >60L/s per person

||
*Administrative

controls

*Clean air supply >20 AC/h
*Overpressure rooms
|-
|}

For this reason, a burden is placed on the building services design to ensure that the utilities and services provided do not hinder efforts to manage airborne-infection control

The [[Building Engineering Services#APR Ventilation Risk Matrix|matrix presented above]] is proposed for consideration when planning mechanical building ventilation for airborne IPC.

'''Table 24.5''' gives further guidance on ventilation rates for specific areas.

For further information regarding the requirements for airborne-infection precaution rooms, refer to Part C, Section 23.3 of this document and the [[Infection Prevention and Control]].

South Africa does not have a uniform formal policy regarding the classification and design of infection prevention and control zones. Provision of multi-bed patient accommodation and internal waiting areas for outpatients is common practice in South Africa.

===Ventilation requirements===
====Natural ventilation====
Due to the high capital outlay required, medical facilities in countries defined as developing, such as South Africa, are generally not provided with “traditional” engineering control measures, such as ventilation, to achieve acceptable environmental management.
-Dr S A Parsons, 2002

#Natural ventilation is driven by a combination of thermo-convective or buoyancy effects and wind pressure. Since the drivers of natural ventilation are inherently variable, natural ventilation has high variability in effectiveness.
#In addition to the variability of the drivers of natural ventilation, the responses of the occupants of a space, by opening and closing windows and doors, could have a negative impact on predicting a natural ventilation system’s performance. For this reason, it is recommended that, where natural ventilation is considered as the primary ventilation mode, dedicated and controlled ventilation openings are designed and created in the building.
#For additional guidance on natural ventilation design, the CIBSE Applications Manual AM10, WHO Natural ventilation for infection control in health-care settings or similar manuals can be consulted<ref>AM10: Natural ventilation in non domestic buildings, CIBSE, 2005, ISBN: [https://www.cibse.org/Knowledge/knowledge-items/detail?id=a0q20000008I7m2AAC 9781903287569]</ref><ref>Natural ventilation for infection control in health-care settings, WHO guidelines [https://www.who.int/water_sanitation_health/publications/natural_ventilation/en/ 2009]</ref>
#Peak and minimum internal temperatures for summer and wintertime respectively should be calculated or thermally modelled for space.
#The design parameters for internal spaces can be found in the detailed room-requirement sheets of the guidance documents of the various functional units. Where these room-requirement sheets are absent or lacking adequate information, the data contained in this document may be used.
#Where the internal design condition cannot be met, the following additional design interventions should be considered for implementation, singly or in combination, in the listed order of preference :
##Reduce solar and internal heat gains
##Using thermal mass to move room temperature extremes to outside of occupancy periods.
##Change occupancy schedules seasonally to improve indoor comfort conditions (e.g. shift consultation hours from or towards the warmest daytime hours during summer or winter respectively)
##Introducing passive cooling or heating strategies
##Increasing ventilation rates
##Providing mechanical cooling or heating
#Where natural ventilation alone cannot achieve the required air quality, quantity and consistency, mixed-mode ventilation shall be considered as a solution preferred over full mechanical ventilation. Mixed-mode ventilation is considered an assisted type of natural ventilation. Here fans are used in combination with damper-controlled ventilation openings to ensure minimum ventilation rates are achieved.
#Where mixed-mode ventilation cannot achieve the required air quality, quantity or consistency, mechanical ventilation may be considered as a solution.

====Mechanical ventilation and air-conditioning====

#Where the quantity and quality of air within a space can be maintained to a satisfactory degree of consistency, natural ventilation should always be the preferred solution.
#The design parameters for internal spaces should be found in the detailed room-requirement sheets published in the individual IUSS guidance documents of the various functional units.
#Where these room-requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

=====Temperature, Relative Humidity (RH) and fresh air requirements=====

#The [[wikipedia:Thermal_comfort#:~:text=The%20adaptive%20model%20is%20based,different%20times%20of%20the%20year.|adaptive approach to thermal comfort]] will result in designs with broader acceptable temperature ranges and thereby greater energy efficiency<ref>de Dear, Richard; Brager, Gail (1998). "Developing an adaptive model of thermal comfort and preference". ''ASHRAE Transactions''. '''104''' (1): 145–67.</ref>. The following aspects have been found to influence the perception of thermal comfort in a space
##Climate and social custom
##Rate of temperature drift >1°C daily and 3°C weekly
##Exponentially time-weighted mean outdoor temperatures
#For the majority of occupied spaces, unless otherwise indicated, a temperature range of 18-28°C is acceptable, although the level of gowning of the patients and staff needs to be considered in the design
#Clinical practices seldom use explosive anaesthetic gases and the requirement for humidity control from this perspective is generally outdated. Direct humidity control is only required in a select few specialised areas. In general, humidity control is indirect, but the designer should consider the resultant humidity levels and the impact on comfort levels in the space.

Table 3: Specialist ventilation systems, provides a list of spaces that have particular temperature and humidity requirements that are critical to the effective provision of healthcare.
{{Cleanup}}

=====Zoning of a building=====

#Where the choice between a central and a local ventilation plant needs to be made, the following points should be considered:
#*Fire compartmentalization
#**Air-handling unit (AHU) sizing
#**Duct sizing
#**Occupancy schedules
#**Occupancy activity levels
#**Building, environmental and equipment heat loads
#**Airborne contamination control
#**Tenancy, functional unit or utility metering
#**Zoning of ventilation systems has a large impact on ventilation efficiency and effectiveness.

=====Minimum fresh air requirements=====

#For minimum fresh air requirements refer to the National Building Regulations and relevant IUSS Infrastructure Guidance Document. Where any apparent conflict between the functional requirements and the “deemed to satisfy” guidance emerges, the rational design route to regulatory compliance would need to be followed so as not to compromise any system’s functionality.
#Where odour control is a consideration, a ventilation rate of 10 litres per second per person may be used.
#Where airborne cross infection is controlled primarily through dilution and natural ventilation, medium and high risk areas require 60 or 160 litres per second per person respectively.
#Where airborne cross infection is controlled primarily through dilution and forced ventilation, medium and high risk areas require 60 or 80 litres per second per person respectively.
#Ventilation rates
#Air change rates per hour (AC/h) are specified in this document for a room with ceiling height of 3m. Where ceiling heights are increased these rates can be reduced, and vice versa.
#Minimum ventilation rates quoted as air changes per hour should be complied with together with the recommended rate of fresh air per occupant
#Supply-only vs balanced ventilation systems
##Supply-only ventilation systems do not supply air to all spaces individually, but instead supply air to only the least contaminated or most critical space. Air is then allowed to cascade from the “clean” core to adjacent and auxiliary spaces. Where this type of system is employed, it is critical to be aware of and control the risk of contamination generated in the clean core and permeating through the entire system. This type of system is not appropriate for thoracic and sepsis theatres or areas where unpleasant or noxious odours, fumes and vapours may be generated. It is also important to ensure and prove that the statutory conditions for ventilation and fresh air rates are met for all spaces. 

17. Airborne contamination-control concepts 

17.1. Airborne contamination control often requires the application of one or more of the concepts described below since airborne contaminants can be generated both internally and external to the controlled zone. 

17.2. Barrier concept 

17.2.1. The barrier concept relies on airtight enclosures to isolate the contamination source. Typical examples are glove boxes or barrier isolators. 

17.3. Aerodynamic effects 

17.3.1. The displacement concept relies on flushing contaminants away with high volumes of air at relatively low velocity. 

17.3.2. The dilution concept involves reducing contamination levels in a space by diluting them with quantities of "clean" air. The ventilation rate required is a function of the required contamination level, the rate of generation of contaminants in the space, and the ventilation efficiency. 

17.3.3. The pressure-differential concept relies on the pressure differential developed between spaces when "clean" air cascades through small orifices, such as door gaps and pressure-control dampers. The pressure differential, and resulting airflow developed, prevents contaminants from moving into higher pressure “clean” areas from lower pressure "dirty" areas. The following diagram gives indicative values for infiltration and exfiltration rates associated with varying pressure differentials (Pa) and opening sizes (m²)

====Medical gas installations====
====Electrical installations====
====Electronic installations====
====Wet Services====
====Lifts====

==COMMISSIONING AND HANDOVER==
===Deliverables===
===Commissioning of ventilation systems===
==EXAMPLES==
===Mechanical system configurations===

==REFERENCES==
<references />

==LIST OF ABBREVIATIONS==
==LIST OF DEFINITIONS==
[[Category:Crosscutting Issues]]

Ventilation and COVID-19

2020-07-21T07:34:42Z

Peta: /* Aircraft Transmission Studies */

[[Category:COVID-19]]
[[Category:Crosscutting Issues]]

==Context==
This article aims to to contextualize COVID-19 related ventilation guidelines in a field of developing clinical evidence. This is done with the hope of empowering the reader to scrutinize proposed interventions within this context and employ appropriate and efficient solutions. The information and guidance in this article is the developing opinion of the author and does not represent any regulatory or institutional mandate or authority. The evidence supporting this opinion is evolving and therefore the opinion is similarly subject to change. The reader is encouraged to return to this article frequently to review any changes additions or updates highlighted in the history tab above.

Discussion and contributions are similarly welcomed in the discussion tab above.[https://thehillside.info/index.php?title=Talk:Ventilation_and_COVID-19#section1]

==Background==

===Transmission routes===
SARS-CoV-2 has caused many to revisit their understanding of droplet and airborne transmission. These two transmission mechanisms form a continuum, but the following is generally accepted:

*''Infectious'' particles <5μm in size can remain suspended and viable for many hours and these contribute to the risk of '''airborne transmission'''.
*'''Droplet transmission''' involves larger particles which can also spread through the air for some distance, but the range of transmission is generally considered to be less than 2 meters where after particles fall out of the breathing zone. It is important to remember that within this 2 m distance these larger droplets are essentially 'airborne' and diluting ventilation systems have little effect on reducing the risk of near-range droplet transmission<ref>Liu, L., Li, Y., Nielsen, P. V., Wei, J. & Jensen, R. L. Short-range airborne transmission of expiratory droplets between two people. Indoor Air 1–11 (2016) doi:10.1111/ina.12314.</ref>.

Droplet precautions, therefore, include standard precautions like PPE, hand washing and distancing, while airborne precautions include negative pressure isolation, respiratory protection, special exhaust or filtration regimes, etc.

Diseases seldom obey only one mode of transmission (obligatory transmission) but often have preferences (preferential transmission) while occasionally exploiting circumstances which provide rare opportunities for transmission (opportunistic routes). SARS-COV-2 is understood to be '''preferentially droplet and contact spread''' (a form of droplet spread where droplets can settle on fomites) with possible rare and opportunistic airborne spread, although an extensive outbreak review revealed no indication of airborne spread<ref>https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>.

===Airborne Transmission===
There is still little strong evidence of common long-range airborne transmission in the sense of droplet nucleation, as with TB and measles<ref>World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) 16-24 February 2020 [Internet]. Geneva: World Health Organization; 2020 Available from: [https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf]</ref>. Where evidence of airborne transmission has been reported, this can be seen in the context of opportunistic long-range droplet spread<ref> Wenzhao Chen, Nan Zhang, Jianjian Wei, Hui-LingYen, and Yuguo Li, “Short-range airborne route dominates exposure of respiratory infection during close contact,” medRxiv preprint, https://doi.org/10.1101/2020.03.16.20037291</ref>. A discussion contextualizing the reported cases of airborne transmission is discussed below.

====van Doremalen et al (NEMJ 2020)====
The van Doremalen SARS-CoV-2 survival study<ref name="van Doremalen">Neeltje van Doremalen, Trenton Bushmaker, Dylan H. Morris, Myndi G. Holbrook, Amandine Gamble, Brandi N. Williamson, Azaibi Tamin, Jennifer L. Harcourt, Natalie J. Thornburg, Susan I. Gerber, James O. LloydSmith, Emmie de Wit, and Vincent J. Munster, “Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1,” The New England Journal of Medicine (2020), DOI: 10.1056/NEJMc2004973 [https://www.nejm.org/doi/pdf/10.1056/NEJMc2004973?articleTools=true]</ref> is often incorrectly reported to have shown that SARS-CoV-2 can remain viable in air for extended periods. No evidence for long range airborne viability has yet been found outside of lab settings. SARS-CoV-2 virus found dispersed at long range has not been cultured to prove viability and many studies have failed to detect it directly in air in quantities substantial enough to culture<ref>Faridi, S. et al. A field indoor air measurement of SARS-CoV-2 in the patient rooms of the largest hospital in Iran. Sci. Total Environ. 725, 1–5 (2020).</ref><ref>Liu, Y. et al. Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals. Nature (2020) doi:10.1038/s41586-020-2271-3.</ref>. Correlations between culture viability, particle size and the real world infectious quantum were not described in this study<ref name="van Doremalen" /> as it was not the study's intention to claim COVID-19 was airborne. A more recent pre-publication article has made similar findings<ref>Fears SC, Klimstra WB, Duprex P, Hartman A, Weaver SC, Plante KS, et al. Persistence of severe acute respiratory syndrome coronavirus 2 in aerosol suspensions. Emerg Infect Dis. 2020 Sep [''date cited'']. <nowiki>https://doi.org/10.3201/eid2609.201806</nowiki></ref> but this has significant problems with equipment standardization and repeatability. More importantly, similar lab studies have also demonstrated a 3h airborne survival for viral strains such as Ebola not considered to be airborne<ref>Robert Comparison of the Aerosol Stability of 2 Strains of Zaire ebolavirus From the 1976 and 2013 Outbreaks Robert J. Fischer, Trenton Bushmaker, Seth Judson, Vincent J. Munster
J Infect Dis. 2016 Oct 15; 214(Suppl 3): S290–S293. Published online 2016 Oct 4. doi: 10.1093/infdis/jiw193 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5050463/</ref>. This makes the direct application of this lab study in real-world settings problematic. Therefore, the understanding of the mechanisms of COVID-19 transmission is still largely reliant on what is understood of SARS (SARS-CoV-1)<ref>Isao Arita, Kazunobu Kojima, and Miyuki Nakane, “Transmission of severe acute respiratory syndrome,” Emerging. Infectious Diseases 9 No. 9 (2003):1183-84, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016764/].</ref>.

====Guangzhou Restaurant Outbreak (2020)====
[[File:Guangzhou Restaurant COVID-19 2020.png|thumb|Plan of COVID-19 outbreak in Guangzhou Restaurant 2020<ref name=":0">Lu, J., Gu, J., Li, K., Xu, C., Su, W., Lai, Z....Yang, Z. (2020). COVID-19 Outbreak Associated with Air Conditioning in Restaurant, Guangzhou, China, 2020. ''Emerging Infectious Diseases'', ''26''(7), 1628-1631. <nowiki>https://dx.doi.org/10.3201/eid2607.200764</nowiki>.[https://wwwnc.cdc.gov/eid/article/26/7/20-0764_article]</ref>]]
The 2020 outbreak of COVID-19 in a restaurant in Guangzhou<ref name=":0" /> raises some important questions around the airborne spread of the disease. This study shows that the transmission range of COVID-19 may exceed the generally prescribed separation distance of 1m under certain conditions, but fails to do so convincingly. Confounding issues that are not addressed adequately in the articles conclusion include:

*the high probability of asymptomatic or pre-symptomatic spread of the virus from members of the index case's family<ref>How Coronavirus Infected Some, but Not All, in a Restaurant, Chang, K (2020) https://www.nytimes.com/2020/04/20/health/airflow-coronavirus-restaurants.html</ref>
*the possibility of onward transmission within family groups after the restaurant exposure is acknowledged but dismissed without discussion
*the difference in exposure times<ref>https://english.elpais.com/spanish_news/2020-06-17/an-analysis-of-three-covid-19-outbreaks-how-they-happened-and-how-they-can-be-avoided.html</ref> between tables (C-B )and (E-F) is not adequately addressed
*The overcrowded and under ventilated conditions in the restaurant.

This is a seminal event in the study of SARS-CoV-2 transmission, but we should be cautious to use it a clear evidence if airborne transmission where similar events are not widespread by now.

===='''South Korea Call Centre Outbreak 2020'''====
[[File:South Korea Call Centre Outbreak COVID-19 2020.png|thumb|Floor plan of South Korea Call Centre Outbreak COVID-19 2020]]
In this pre-publication report, the outbreak in a call-centre on the 11th story of a South Korean office block<ref>Park SY, Kim YM, Yi S, Lee S, Na BJ, Kim CB, et al. Coronavirus disease outbreak in call center, South Korea. Emerg Infect Dis. 2020 Aug [''date cited'']. <nowiki>https://doi.org/10.3201/eid2608.201274</nowiki></ref> offer some extraordinary insights but leaves many questions open. The distribution of the attacks is alarming in the call centre room, but is significantly reduced in adjacent room on the same floor.

The following is a summary of the findings:

*It appears as if the outbreak followed physical compartmentalization and not HVAC zoning although an HVAC plan of the building was not discussed.
*It is clear that COVID-19 is exceptionally contagious in crowded office settings.
*Lobbies and lifts contributed little to spread.
*Exposure time correlated with transmission risk.

Questions that remain:

*HVAC zoning or an HVAC plan of the building was not discussed.
*Ratios of male and female cases would have offered insight into the roles of bathrooms in COVID-19 spread.
*A review of vertical transport characteristics may have offered insight into the vertical distribution of case through the building.

===Aircraft Transmission Studies===
SARS and COVID-19 outbreaks on commercial aircraft have proven to be remarkedly rare. This may be due to the high ventilation rates<ref>Mangili, A., & Gendreau, M. A. (2005). Transmission of infectious diseases during commercial air travel. ''Lancet (London, England)'', ''365''(9463), 989–996. <nowiki>https://doi.org/10.1016/S0140-6736(05)71089-8</nowiki></ref>. Studies tracing contacts on flights seem to show multiple cases of very low to zero transmission rates with the transmission events raising disproportional alarm<ref name=":3">Olsen et al, N Engl J Med 2003; 349:2416-2422Transmission of the Severe Acute Respiratory Syndrome on Aircraft, DOI: 10.1056/NEJMoa031349 [https://www.nejm.org/doi/full/10.1056/nejmoa031349]</ref><ref>CMAJ 2020 April 14;192:E410. doi: 10.1503/cmaj.75015 [https://www.cmaj.ca/content/cmaj/192/15/E410.full.pdf]</ref>. The context of the scope of aircraft outbreak findings highlights the role ventilation has in creating safe environments, but similarly reveals the low risk levels associated with airborne transmission of SARS or COVID-19.

====Amoy Gardens SARS Outbreak (2003)<ref name=":1">McKinney KR, Gong YY, Lewis TG. Environmental transmission of SARS at Amoy Gardens. ''J Environ Health''. 2006;68(9):26-52.</ref>====
Studies, which indicate the Amoy Gardens building's SARS outbreaks' transmission was via the airborne route<ref name=":1" />, commonly reference the prevailing wind between buildings. It should be noted that, since these buildings are about 60m apart the environmental dilution and concentration decay effects are so strong it is not feasible that an infectious dose persists at that range. Similarly, the possibility that air can commute out of one window and into another needs to account for these dilution effects before assumptions of transmission can be drawn. These studies do not sufficiently account for dilution, infectious doses and pathogen survival rates. A more feasible hypothesis is that the Amoy Gardens intra-building spread was through re-aerosolisation of contaminated waste water coming from the faulty plumbing system. Similar outbreaks have more recently been found<ref name=":2">Bhowmick, G.D., Dhar, D., Nath, D. et al. Coronavirus disease 2019 (COVID-19) outbreak: some serious consequences with urban and rural water cycle. npj Clean Water 3, 32 (2020). https://doi.org/10.1038/s41545-020-0079-1</ref>.

====Other studies====
Studies which have found real-world SARS-CoV-2 in air, ducting and on extraction fans have so far failed to prove that the virus found was still viable<ref>Santarpia et al, “Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center,. medRxiv preprint (2020), [https://doi.org/10.1101/2020.03.23.20039446]</ref><ref>Po Ying Chia et al, 2020 (Preprint) “Detection of Air and Surface Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in Hospital Rooms of Infective Patients,” medRxiv preprint (2020), https://doi.org/10.1101/2020.03.29.20046557 [https://www.medrxiv.org/content/10.1101/2020.03.29.20046557v2.full.pdf]</ref>. Air sampling studies have failed to detect viable SARS-CoV-2<ref>Ong SWX, Tan YK, Chia PY, et al. Air, Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient. ''JAMA.'' 2020;323(16):1610–1612. doi:10.1001/jama.2020.3227</ref>.

It has been suggested that high temperature and humidity would reduce the spread of the virus<ref>Chin, A. W. H. et al. Stability of SARS-CoV-2 in different environmental conditions. The Lancet Microbe 0–4 (2020) doi:10.1016/s2666-5247(20)30003-3.</ref><ref>Pyankov, O. V., Bodnev, S. A., Pyankova, O. G. & Agranovski, I. E. Survival of aerosolized coronavirus in the ambient air. J. Aerosol Sci. 115, (2018).</ref>. The temperature ranges suggested (>50°C) are beyond what anyone could endure in an ICU but the humidity ranges of between 40-60% are achievable. The high humidity slows the nucleation of the viral droplet and increases its settling speed, thereby reducing its range.
====High Risk Settings (ICU)====
Much of the work being done to understand the transmission mechanism of COVID-19 is focused on community transmission. It is important to remember that transmission risk in an ICU will not be the same as in homes and workplaces. The conditions and procedures in ICUs could promote transmission - see WHO 2020 below<ref name="WHO 2020">WHO 2020, Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>. Firstly, in a COVID ICU unit, the contamination source strength is much higher than other spaces since infected patients are congregated there. These are presumably ill patients with high viral shedding. Secondly, procedures like intubation are understood to release high quantities of aerosolized particles, unlike with general talking or coughing. Additionally, viral shedding through talking and coughing can be more readily mitigated than from intubation.

===Fecal-Oral Transmission===
Fecal oral route of transmission is acknowledged for COVID-19<ref>Pan Y, Zhang D, Yang P, Poon LLM, Wang Q. Viral load of SARS-CoV-2 in clinical samples. Lancet Infect Dis. 2020;20(4):411-2.</ref> and considerations for waste water management are discussed [[SARS-CoV-2 is found in faecal matter|here]] and [https://doi.org/10.1016/j.scitotenv.2020.139076 here]<ref>Kitajima et al,SARS-CoV-2 in wastewater: State of the knowledge and research needs,Science of The Total Environment,Volume 739,2020,139076,ISSN 0048-9697,<nowiki>https://doi.org/10.1016/j.scitotenv.2020.139076</nowiki></ref>. This transmission route indirectly affects ventilation system design as special consideration should be given to common scenarios where the aerosolisation of contaminated wastewater is a possibility such as in bathrooms, sluice rooms and slurry pumping. These spaces should be well-ventilated and kept under negative pressure relative to adjacent spaces.

==Institutional Guidance==
===WHO===
The WHO's advice regarding SARS-CoV-2 transmission during clinical interventions is as follows:
''"In the context of COVID-19, airborne transmission may be possible in specific circumstances and settings in which procedures or support treatments that generate aerosols are performed; i.e., endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, turning the patient to the prone position, disconnecting the patient from the ventilator, non-invasive positive-pressure ventilation, tracheostomy, and cardiopulmonary resuscitation."'' - WHO 2020<ref name="WHO 2020" /> 

While the WHO's position acknowledges the increased risk of transmission in overcrowded and under-ventilated spaces, the appropriate response is not to increase prescribed general ventilation rates, but rather to avoid overcrowding and maintain ventilation systems correctly.
===US-CDC===
The CDC's advice regarding SARS-CoV-2 transmission is still nearly identical to its guidance for SARS-CoV-1:
''"The primary transmission of COVID-19 is from person-to-person through respiratory droplets. These droplets are released when someone with COVID-19 sneezes or coughs. COVID-19 can also be spread when you are in close contact with someone who is sick (e.g., shaking hands or talking). A physical distance of at least 1 meter (3ft) between persons is suggested by the World Health Organization (WHO) to avoid infection, although some WHO member states have recommended maintaining greater distances whenever possible. Respiratory droplets can land on objects or surfaces around the person when they cough or talk, and people can then become infected with COVID-19 from touching these objects or surfaces and then touching their eyes, nose or mouth. Recent data suggests that there can be transmission of COVID-19 through droplets of those with mild symptoms or those who do not feel ill"'' <ref>https://www.cdc.gov/sars/about/faq.html</ref><ref>https://www.cdc.gov/sars/about/faq.html</ref>

The US-CDC's recommendations regarding inpatient accommodation for SARS includes the comment,
"Experience in some settings in Taiwan and Toronto demonstrated that cohorting SARS patients, without use of AIIRs, effectively interrupted transmission"<ref>US-CDC,2005, https://www.cdc.gov/sars/guidance/i-infection/healthcare.html</ref>
The CDC's guidance is consistent with the full context of hierarchical risk-based infection control and is suitably cognizant of variously resourced settings.
"Airborne Infection Isolation Rooms (AIIRs) (See definition of AIIR in appendix) should be reserved for patients who will be undergoing aerosol generating procedures (See Aerosol Generating Procedures Section)."<ref>Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (updated July 9, 2020)[https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html]</ref>
This nuanced approach is difficult to tease out of the guidance from engineering societies.

===ASHRAE===
While the US-CDC and WHO maintains that the airborne transmission is possible but not common or of primary concern, ASHRAE (being an association dedicated to ventilation engineering) focuses on the airborne component.
"Transmission of SARS-CoV-2 through the air is sufficiently likely that airborne exposure to the virus should be controlled. Changes to building operations, including the operation of heating, ventilating, and air-conditioning systems, can reduce airborne exposures"<ref>Q: Does ASHRAE’s guidance agree with guidance from WHO and CDC?[https://www.ashrae.org/file%20library/technical%20resources/covid-19/does-ashrae-s-guidance-agree-with-guidance-from-who-and-cdc.pdf]</ref>
ASHRAE makes useful distinctions between guidance for healthcare<ref>ASHRAE healthcare C19 guidance (ASHRAE 2020) [https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-healthcare-c19-guidance.pdf]</ref>, residential <ref>ASHRAE residential c19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-residential-c19-guidance.pdf]</ref><ref>COVID 19 guidance for multifamily building owners-managers (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/covid-19-guidance-for-multifamily-building-owners_managers.pdf]</ref>, commercial <ref>ASHRAE commercial C19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-commercial-c19-guidance.pdf]</ref> and schools<ref>ASHRAE Schools C19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-schools-c19-guidance.pdf</ref>, but doesn't significantly address risk categories specifically in healthcare or resource limited settings.
===REHVA===
REHVA's temporary guidance is limited to commercial and public buildings<ref>REHVA COVID-19 guidance document, April 3, 2020[https://www.rehva.eu/fileadmin/user_upload/REHVA_COVID-19_guidance_document_ver2_20200403_1.pdf]</ref>. Similar to ASHRAE, REHVA focusses on engineering controls for airborne transmission. REHVA acknowledges importance of droplet precautions and the lack of quality evidence for airborne transmission, but draws the conclusion that SARS-CoV-2 RNA found in ventilation ducting implies airborne transmission, even though these real world studies have not yet proven viability of these particles. REHVA also draws the airborne conclusion from the van Doremalen study<ref name="van Doremalen" /> out of its intended comparative context.

===IUSS (2014)===
The [[Infrastructure_Unit_System_Support|IUSS]] Building Engineering Services Guidelines<ref>Building Engineering Services (2014)[https://iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-services]</ref>, which is mandated for new buildings by provincial departments of health by reference in Government Notice R116<ref>Government Notice R116 (17 Feb 2014)[https://iussonline.co.za/docman/gazettes/116-notice-37348/file]</ref>, describes risk based ventilation criteria which are broadly appropriate for COVID-19, if not excessive. This guideline was developed with control measures for the current TB epidemic in mind. These measures would be more than appropriate for most healthcare spaces. The guidance recommends no recirculation of air between theatres and adjacent spaces but does not prohibit cascading from surgeries to adjacent spaces. Therefore, confirmed COVID-19 patients should only be treated in negative pressure operating rooms that comply with the guidelines.

===SANS 10400-O (2011)===
{{Expand}}

==Air-Conditioning, Ventilation and COVID-19==
It is important to differentiate between ventilation and air-conditioning when discussion indoor contamination. When the term ventilation is used, it describes any system that induces decontaminated, fresh or outdoor-air to enter a space by the application of supply or extraction systems. Diluting ventilation is the most commonly used regime. Other modes of contaminant removal include displacement and local exhaust ventilation systems, each of which requires its own nuanced discussion as they pertain to infection control.

Air-conditioning in contrast, refers to only the mechanical cooling or heating system, sometimes installed directly in a space (Spit-AC), to offer thermal comfort and sometimes humidity control. In-room air-conditioning systems that circulate air directly within a space with no dilution or extraction can directly offer no reduction in airborne contaminant levels. In some instances they can even assist in the distribution of contaminants.

Openable windows can be considered as ventilation apertures and, in most cases, offer highly effective ventilation. Unfortunately, this is sometimes at the expense of indoor comfort. Even though long range droplet transmission of SARS-CoV-2 is relatively low in comparison to short range transmission, encouraging occupants to open windows will reduce that risk. Allowing occupants to use air-conditioning to either heat or cool a space while windows are open can improve levels of open window compliance which is more important than limiting AC use for reducing long range transmission. An additional strategy to both improve open window compliance and reduce AC usage would be to relax strict corporate dress codes as this can improve thermal comfort levels seasonally.

==Engineering Response==
Ventilation society guidance understandably bears the risk of being biased toward over-prescribing solutions over which engineers have the greatest understanding and control. It is within this context that the valuable guidance published online by REHVA and ASHRAE should be considered. Revamping existing ventilation systems in resource-constrained healthcare settings to meet admittedly overly-cautious guidance should not be conducted without an informed investment case.
"In these resource limited settings, it needs to be carefully considered whether resources are allocated to clinical capacity or to possibly unnecessary ventilation when the benefits of these criteria may be comparatively marginal."

Without good viability studies of the viral particles found in air or ventilation systems, no firm guidance can be offered regarding the rate of reduction for SARS-CoV-2 viability with time and distance. Until that time it would be prudent to assume that the virus should only be considered as airborne under special and rare conditions, based on the guidance of the WHO, and these conditions should be avoided. This would determine that we have different filtration and ventilation approaches between COVID-ICUs, general indoor public spaces and spaces with a potential for high density occupation. Engineers should not be tempted to assume or argue that all indoor spaces bear the same risk profile.

For high-risk spaces it may be prudent to implement temporary measures to limit transmission risk to the minimum possible. In order of priorities, engineering interventions include:

#decongest indoor spaces to the minimum possible occupancy levels
#open windows to outside when occupational health, safety and security are not compromised
#increase HVAC fresh air rates to maximum possible levels
#reduce HVAC recirculation levels to minimum possible levels
#flush buildings with fresh air before and after daily occupancy

The following matrix is intended to guide our design responses for a sample of space types
{| class="wikitable"
|+Risk Response Matrix
!Space Type
!Risk
!Initial Risk
!Engineering Response
!Residual Risk
|-
| rowspan="2" |ICU
|Transmission in ICU
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Low
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Where high risks are associated with adjacent spaces, ventilate ICU in accordance with IUSS Guidelines for Airborne Precaution Rooms
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |Surgeries
|Transmission in Theatre
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs,
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Moderate
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Surgeries on identified COVID-19 patients in negative pressure theatres only.
##No recirculation to adjacent spaces (for negative pressure theatres)
##Ensure compliance with contact, droplet and airborne precautions for staff
##Where high risks are associated with adjacent spaces, ventilate the operating room in accordance with IUSS Guidelines for Airborne Precaution Rooms or sepsis theatres
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |COVID Wards
|Transmission within COVID-19 Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for general wards
#Keep available windows open when safe and secure
#Ensure compliance with contact, droplet and airborne precautions
|Low
|-
|Transmission to Adjacent spaces
|High
| 

#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
##Increase ventilation rates in adjacent areas (passages)
##Positive pressure relative to COVID wards
##Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
##Extraction systems to discharge safely at high-level
|Low
|-
|General wards
|Transmission within and from Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for General Wards
|Low
|-
|Emergency centre
|Transmission within EC
|High
|
#Reduce number of occupants to only essential staff and caregivers
#Screen and fast-track patients with respiratory illness symptoms
#Isolate persons under investigation for COVID-19
##Isolation rooms ventilated in accordance with IUSS guidance for airborne precaution rooms
|Moderate
|-
|Hospital Waiting Areas
|Transmission within waiting room
|High
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with IUSS Guidelines for Waiting Areas
|Moderate
|-
|Other public waiting spaces
|Transmission within waiting room
|Moderate
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with Building Regulations
|Moderate
|}

===Conclusion===
Therefore, assuming ventilation systems in South Africa have been designed in accordance with the IUSS guidance, there should be little reason to change their configuration or pressurization unless general areas are repurposed as airborne precaution rooms. Risk assessments should be conducted for ICUs and COVID-19 wards immediately adjacent to public waiting areas or other high traffic areas, with corrective actions including but not limited to reducing occupancy times and rates for these areas and adjusting distancing rules.

 
----

==Notes and References==
[[Category:Reference Desk]]
[[Category:COVID-19]]
[[Category:ICU]]
<references />
[[Category:ASHRAE]]
[[Category:REHVA]]
[[Category:IUSS]]
[[Category:Airborne Infection control]]
[[Category:Airborne Contamination Control]]

Ventilation and COVID-19

2020-07-21T07:33:10Z

Peta: /* South Korea Call Centre Outbreak 2020 */

[[Category:COVID-19]]
[[Category:Crosscutting Issues]]

==Context==
This article aims to to contextualize COVID-19 related ventilation guidelines in a field of developing clinical evidence. This is done with the hope of empowering the reader to scrutinize proposed interventions within this context and employ appropriate and efficient solutions. The information and guidance in this article is the developing opinion of the author and does not represent any regulatory or institutional mandate or authority. The evidence supporting this opinion is evolving and therefore the opinion is similarly subject to change. The reader is encouraged to return to this article frequently to review any changes additions or updates highlighted in the history tab above.

Discussion and contributions are similarly welcomed in the discussion tab above.[https://thehillside.info/index.php?title=Talk:Ventilation_and_COVID-19#section1]

==Background==

===Transmission routes===
SARS-CoV-2 has caused many to revisit their understanding of droplet and airborne transmission. These two transmission mechanisms form a continuum, but the following is generally accepted:

*''Infectious'' particles <5μm in size can remain suspended and viable for many hours and these contribute to the risk of '''airborne transmission'''.
*'''Droplet transmission''' involves larger particles which can also spread through the air for some distance, but the range of transmission is generally considered to be less than 2 meters where after particles fall out of the breathing zone. It is important to remember that within this 2 m distance these larger droplets are essentially 'airborne' and diluting ventilation systems have little effect on reducing the risk of near-range droplet transmission<ref>Liu, L., Li, Y., Nielsen, P. V., Wei, J. & Jensen, R. L. Short-range airborne transmission of expiratory droplets between two people. Indoor Air 1–11 (2016) doi:10.1111/ina.12314.</ref>.

Droplet precautions, therefore, include standard precautions like PPE, hand washing and distancing, while airborne precautions include negative pressure isolation, respiratory protection, special exhaust or filtration regimes, etc.

Diseases seldom obey only one mode of transmission (obligatory transmission) but often have preferences (preferential transmission) while occasionally exploiting circumstances which provide rare opportunities for transmission (opportunistic routes). SARS-COV-2 is understood to be '''preferentially droplet and contact spread''' (a form of droplet spread where droplets can settle on fomites) with possible rare and opportunistic airborne spread, although an extensive outbreak review revealed no indication of airborne spread<ref>https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>.

===Airborne Transmission===
There is still little strong evidence of common long-range airborne transmission in the sense of droplet nucleation, as with TB and measles<ref>World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) 16-24 February 2020 [Internet]. Geneva: World Health Organization; 2020 Available from: [https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf]</ref>. Where evidence of airborne transmission has been reported, this can be seen in the context of opportunistic long-range droplet spread<ref> Wenzhao Chen, Nan Zhang, Jianjian Wei, Hui-LingYen, and Yuguo Li, “Short-range airborne route dominates exposure of respiratory infection during close contact,” medRxiv preprint, https://doi.org/10.1101/2020.03.16.20037291</ref>. A discussion contextualizing the reported cases of airborne transmission is discussed below.

====van Doremalen et al (NEMJ 2020)====
The van Doremalen SARS-CoV-2 survival study<ref name="van Doremalen">Neeltje van Doremalen, Trenton Bushmaker, Dylan H. Morris, Myndi G. Holbrook, Amandine Gamble, Brandi N. Williamson, Azaibi Tamin, Jennifer L. Harcourt, Natalie J. Thornburg, Susan I. Gerber, James O. LloydSmith, Emmie de Wit, and Vincent J. Munster, “Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1,” The New England Journal of Medicine (2020), DOI: 10.1056/NEJMc2004973 [https://www.nejm.org/doi/pdf/10.1056/NEJMc2004973?articleTools=true]</ref> is often incorrectly reported to have shown that SARS-CoV-2 can remain viable in air for extended periods. No evidence for long range airborne viability has yet been found outside of lab settings. SARS-CoV-2 virus found dispersed at long range has not been cultured to prove viability and many studies have failed to detect it directly in air in quantities substantial enough to culture<ref>Faridi, S. et al. A field indoor air measurement of SARS-CoV-2 in the patient rooms of the largest hospital in Iran. Sci. Total Environ. 725, 1–5 (2020).</ref><ref>Liu, Y. et al. Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals. Nature (2020) doi:10.1038/s41586-020-2271-3.</ref>. Correlations between culture viability, particle size and the real world infectious quantum were not described in this study<ref name="van Doremalen" /> as it was not the study's intention to claim COVID-19 was airborne. A more recent pre-publication article has made similar findings<ref>Fears SC, Klimstra WB, Duprex P, Hartman A, Weaver SC, Plante KS, et al. Persistence of severe acute respiratory syndrome coronavirus 2 in aerosol suspensions. Emerg Infect Dis. 2020 Sep [''date cited'']. <nowiki>https://doi.org/10.3201/eid2609.201806</nowiki></ref> but this has significant problems with equipment standardization and repeatability. More importantly, similar lab studies have also demonstrated a 3h airborne survival for viral strains such as Ebola not considered to be airborne<ref>Robert Comparison of the Aerosol Stability of 2 Strains of Zaire ebolavirus From the 1976 and 2013 Outbreaks Robert J. Fischer, Trenton Bushmaker, Seth Judson, Vincent J. Munster
J Infect Dis. 2016 Oct 15; 214(Suppl 3): S290–S293. Published online 2016 Oct 4. doi: 10.1093/infdis/jiw193 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5050463/</ref>. This makes the direct application of this lab study in real-world settings problematic. Therefore, the understanding of the mechanisms of COVID-19 transmission is still largely reliant on what is understood of SARS (SARS-CoV-1)<ref>Isao Arita, Kazunobu Kojima, and Miyuki Nakane, “Transmission of severe acute respiratory syndrome,” Emerging. Infectious Diseases 9 No. 9 (2003):1183-84, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016764/].</ref>.

====Guangzhou Restaurant Outbreak (2020)====
[[File:Guangzhou Restaurant COVID-19 2020.png|thumb|Plan of COVID-19 outbreak in Guangzhou Restaurant 2020<ref name=":0">Lu, J., Gu, J., Li, K., Xu, C., Su, W., Lai, Z....Yang, Z. (2020). COVID-19 Outbreak Associated with Air Conditioning in Restaurant, Guangzhou, China, 2020. ''Emerging Infectious Diseases'', ''26''(7), 1628-1631. <nowiki>https://dx.doi.org/10.3201/eid2607.200764</nowiki>.[https://wwwnc.cdc.gov/eid/article/26/7/20-0764_article]</ref>]]
The 2020 outbreak of COVID-19 in a restaurant in Guangzhou<ref name=":0" /> raises some important questions around the airborne spread of the disease. This study shows that the transmission range of COVID-19 may exceed the generally prescribed separation distance of 1m under certain conditions, but fails to do so convincingly. Confounding issues that are not addressed adequately in the articles conclusion include:

*the high probability of asymptomatic or pre-symptomatic spread of the virus from members of the index case's family<ref>How Coronavirus Infected Some, but Not All, in a Restaurant, Chang, K (2020) https://www.nytimes.com/2020/04/20/health/airflow-coronavirus-restaurants.html</ref>
*the possibility of onward transmission within family groups after the restaurant exposure is acknowledged but dismissed without discussion
*the difference in exposure times<ref>https://english.elpais.com/spanish_news/2020-06-17/an-analysis-of-three-covid-19-outbreaks-how-they-happened-and-how-they-can-be-avoided.html</ref> between tables (C-B )and (E-F) is not adequately addressed
*The overcrowded and under ventilated conditions in the restaurant.

This is a seminal event in the study of SARS-CoV-2 transmission, but we should be cautious to use it a clear evidence if airborne transmission where similar events are not widespread by now.

===='''South Korea Call Centre Outbreak 2020'''====
[[File:South Korea Call Centre Outbreak COVID-19 2020.png|thumb|Floor plan of South Korea Call Centre Outbreak COVID-19 2020]]
In this pre-publication report, the outbreak in a call-centre on the 11th story of a South Korean office block<ref>Park SY, Kim YM, Yi S, Lee S, Na BJ, Kim CB, et al. Coronavirus disease outbreak in call center, South Korea. Emerg Infect Dis. 2020 Aug [''date cited'']. <nowiki>https://doi.org/10.3201/eid2608.201274</nowiki></ref> offer some extraordinary insights but leaves many questions open. The distribution of the attacks is alarming in the call centre room, but is significantly reduced in adjacent room on the same floor.

The following is a summary of the findings:

*It appears as if the outbreak followed physical compartmentalization and not HVAC zoning although an HVAC plan of the building was not discussed.
*It is clear that COVID-19 is exceptionally contagious in crowded office settings.
*Lobbies and lifts contributed little to spread.
*Exposure time correlated with transmission risk.

Questions that remain:

*HVAC zoning or an HVAC plan of the building was not discussed.
*Ratios of male and female cases would have offered insight into the roles of bathrooms in COVID-19 spread.
*A review of vertical transport characteristics may have offered insight into the vertical distribution of case through the building.

===Aircraft Transmission Studies===
SARS and COVID-19 Outbreaks on commercial aircraft have proven to be remarkedly rare. This may be due to the high ventilation rates<ref>Mangili, A., & Gendreau, M. A. (2005). Transmission of infectious diseases during commercial air travel. ''Lancet (London, England)'', ''365''(9463), 989–996. <nowiki>https://doi.org/10.1016/S0140-6736(05)71089-8</nowiki></ref>. Studies tracing contacts on flights seem to show multiple cases of very low to zero transmission rates with the transmission events raising disproportional alarm<ref name=":3">Olsen et al, N Engl J Med 2003; 349:2416-2422Transmission of the Severe Acute Respiratory Syndrome on Aircraft, DOI: 10.1056/NEJMoa031349 [https://www.nejm.org/doi/full/10.1056/nejmoa031349]</ref><ref>CMAJ 2020 April 14;192:E410. doi: 10.1503/cmaj.75015 [https://www.cmaj.ca/content/cmaj/192/15/E410.full.pdf]</ref>. The context of the scope of aircraft outbreak findings highlights the role ventilation has in creating safe environments, but similarly reveals the low risk levels associated with airborne transmission of SARS or COVID-19

====Amoy Gardens SARS Outbreak (2003)<ref name=":1">McKinney KR, Gong YY, Lewis TG. Environmental transmission of SARS at Amoy Gardens. ''J Environ Health''. 2006;68(9):26-52.</ref>====
Studies, which indicate the Amoy Gardens building's SARS outbreaks' transmission was via the airborne route<ref name=":1" />, commonly reference the prevailing wind between buildings. It should be noted that, since these buildings are about 60m apart the environmental dilution and concentration decay effects are so strong it is not feasible that an infectious dose persists at that range. Similarly, the possibility that air can commute out of one window and into another needs to account for these dilution effects before assumptions of transmission can be drawn. These studies do not sufficiently account for dilution, infectious doses and pathogen survival rates. A more feasible hypothesis is that the Amoy Gardens intra-building spread was through re-aerosolisation of contaminated waste water coming from the faulty plumbing system. Similar outbreaks have more recently been found<ref name=":2">Bhowmick, G.D., Dhar, D., Nath, D. et al. Coronavirus disease 2019 (COVID-19) outbreak: some serious consequences with urban and rural water cycle. npj Clean Water 3, 32 (2020). https://doi.org/10.1038/s41545-020-0079-1</ref>

====Other studies====
Studies which have found real-world SARS-CoV-2 in air, ducting and on extraction fans have so far failed to prove that the virus found was still viable<ref>Santarpia et al, “Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center,. medRxiv preprint (2020), [https://doi.org/10.1101/2020.03.23.20039446]</ref><ref>Po Ying Chia et al, 2020 (Preprint) “Detection of Air and Surface Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in Hospital Rooms of Infective Patients,” medRxiv preprint (2020), https://doi.org/10.1101/2020.03.29.20046557 [https://www.medrxiv.org/content/10.1101/2020.03.29.20046557v2.full.pdf]</ref>. Air sampling studies have failed to detect viable SARS-CoV-2 <ref>Ong SWX, Tan YK, Chia PY, et al. Air, Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient. ''JAMA.'' 2020;323(16):1610–1612. doi:10.1001/jama.2020.3227</ref>.

It has been suggested that high temperature and humidity would reduce the spread of the virus<ref>Chin, A. W. H. et al. Stability of SARS-CoV-2 in different environmental conditions. The Lancet Microbe 0–4 (2020) doi:10.1016/s2666-5247(20)30003-3.</ref><ref>Pyankov, O. V., Bodnev, S. A., Pyankova, O. G. & Agranovski, I. E. Survival of aerosolized coronavirus in the ambient air. J. Aerosol Sci. 115, (2018).</ref>. The temperature ranges suggested (>50°C) are beyond what anyone could endure in an ICU but the humidity ranges of between 40-60% are achievable. The high humidity slows the nucleation of the viral droplet and increases its settling speed, thereby reducing its range.
====High Risk Settings (ICU)====
Much of the work being done to understand the transmission mechanism of COVID-19 is focused on community transmission. It is important to remember that transmission risk in an ICU will not be the same as in homes and workplaces. The conditions and procedures in ICUs could promote transmission - see WHO 2020 below<ref name="WHO 2020">WHO 2020, Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>. Firstly, in a COVID ICU unit, the contamination source strength is much higher than other spaces since infected patients are congregated there. These are presumably ill patients with high viral shedding. Secondly, procedures like intubation are understood to release high quantities of aerosolized particles, unlike with general talking or coughing. Additionally, viral shedding through talking and coughing can be more readily mitigated than from intubation.

===Fecal-Oral Transmission===
Fecal oral route of transmission is acknowledged for COVID-19<ref>Pan Y, Zhang D, Yang P, Poon LLM, Wang Q. Viral load of SARS-CoV-2 in clinical samples. Lancet Infect Dis. 2020;20(4):411-2.</ref> and considerations for waste water management are discussed [[SARS-CoV-2 is found in faecal matter|here]] and [https://doi.org/10.1016/j.scitotenv.2020.139076 here]<ref>Kitajima et al,SARS-CoV-2 in wastewater: State of the knowledge and research needs,Science of The Total Environment,Volume 739,2020,139076,ISSN 0048-9697,<nowiki>https://doi.org/10.1016/j.scitotenv.2020.139076</nowiki></ref>. This transmission route indirectly affects ventilation system design as special consideration should be given to common scenarios where the aerosolisation of contaminated wastewater is a possibility such as in bathrooms, sluice rooms and slurry pumping. These spaces should be well-ventilated and kept under negative pressure relative to adjacent spaces.

==Institutional Guidance==
===WHO===
The WHO's advice regarding SARS-CoV-2 transmission during clinical interventions is as follows:
''"In the context of COVID-19, airborne transmission may be possible in specific circumstances and settings in which procedures or support treatments that generate aerosols are performed; i.e., endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, turning the patient to the prone position, disconnecting the patient from the ventilator, non-invasive positive-pressure ventilation, tracheostomy, and cardiopulmonary resuscitation."'' - WHO 2020<ref name="WHO 2020" /> 

While the WHO's position acknowledges the increased risk of transmission in overcrowded and under-ventilated spaces, the appropriate response is not to increase prescribed general ventilation rates, but rather to avoid overcrowding and maintain ventilation systems correctly.
===US-CDC===
The CDC's advice regarding SARS-CoV-2 transmission is still nearly identical to its guidance for SARS-CoV-1:
''"The primary transmission of COVID-19 is from person-to-person through respiratory droplets. These droplets are released when someone with COVID-19 sneezes or coughs. COVID-19 can also be spread when you are in close contact with someone who is sick (e.g., shaking hands or talking). A physical distance of at least 1 meter (3ft) between persons is suggested by the World Health Organization (WHO) to avoid infection, although some WHO member states have recommended maintaining greater distances whenever possible. Respiratory droplets can land on objects or surfaces around the person when they cough or talk, and people can then become infected with COVID-19 from touching these objects or surfaces and then touching their eyes, nose or mouth. Recent data suggests that there can be transmission of COVID-19 through droplets of those with mild symptoms or those who do not feel ill"'' <ref>https://www.cdc.gov/sars/about/faq.html</ref><ref>https://www.cdc.gov/sars/about/faq.html</ref>

The US-CDC's recommendations regarding inpatient accommodation for SARS includes the comment,
"Experience in some settings in Taiwan and Toronto demonstrated that cohorting SARS patients, without use of AIIRs, effectively interrupted transmission"<ref>US-CDC,2005, https://www.cdc.gov/sars/guidance/i-infection/healthcare.html</ref>
The CDC's guidance is consistent with the full context of hierarchical risk-based infection control and is suitably cognizant of variously resourced settings.
"Airborne Infection Isolation Rooms (AIIRs) (See definition of AIIR in appendix) should be reserved for patients who will be undergoing aerosol generating procedures (See Aerosol Generating Procedures Section)."<ref>Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (updated July 9, 2020)[https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html]</ref>
This nuanced approach is difficult to tease out of the guidance from engineering societies.

===ASHRAE===
While the US-CDC and WHO maintains that the airborne transmission is possible but not common or of primary concern, ASHRAE (being an association dedicated to ventilation engineering) focuses on the airborne component.
"Transmission of SARS-CoV-2 through the air is sufficiently likely that airborne exposure to the virus should be controlled. Changes to building operations, including the operation of heating, ventilating, and air-conditioning systems, can reduce airborne exposures"<ref>Q: Does ASHRAE’s guidance agree with guidance from WHO and CDC?[https://www.ashrae.org/file%20library/technical%20resources/covid-19/does-ashrae-s-guidance-agree-with-guidance-from-who-and-cdc.pdf]</ref>
ASHRAE makes useful distinctions between guidance for healthcare<ref>ASHRAE healthcare C19 guidance (ASHRAE 2020) [https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-healthcare-c19-guidance.pdf]</ref>, residential <ref>ASHRAE residential c19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-residential-c19-guidance.pdf]</ref><ref>COVID 19 guidance for multifamily building owners-managers (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/covid-19-guidance-for-multifamily-building-owners_managers.pdf]</ref>, commercial <ref>ASHRAE commercial C19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-commercial-c19-guidance.pdf]</ref> and schools<ref>ASHRAE Schools C19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-schools-c19-guidance.pdf</ref>, but doesn't significantly address risk categories specifically in healthcare or resource limited settings.
===REHVA===
REHVA's temporary guidance is limited to commercial and public buildings<ref>REHVA COVID-19 guidance document, April 3, 2020[https://www.rehva.eu/fileadmin/user_upload/REHVA_COVID-19_guidance_document_ver2_20200403_1.pdf]</ref>. Similar to ASHRAE, REHVA focusses on engineering controls for airborne transmission. REHVA acknowledges importance of droplet precautions and the lack of quality evidence for airborne transmission, but draws the conclusion that SARS-CoV-2 RNA found in ventilation ducting implies airborne transmission, even though these real world studies have not yet proven viability of these particles. REHVA also draws the airborne conclusion from the van Doremalen study<ref name="van Doremalen" /> out of its intended comparative context.

===IUSS (2014)===
The [[Infrastructure_Unit_System_Support|IUSS]] Building Engineering Services Guidelines<ref>Building Engineering Services (2014)[https://iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-services]</ref>, which is mandated for new buildings by provincial departments of health by reference in Government Notice R116<ref>Government Notice R116 (17 Feb 2014)[https://iussonline.co.za/docman/gazettes/116-notice-37348/file]</ref>, describes risk based ventilation criteria which are broadly appropriate for COVID-19, if not excessive. This guideline was developed with control measures for the current TB epidemic in mind. These measures would be more than appropriate for most healthcare spaces. The guidance recommends no recirculation of air between theatres and adjacent spaces but does not prohibit cascading from surgeries to adjacent spaces. Therefore, confirmed COVID-19 patients should only be treated in negative pressure operating rooms that comply with the guidelines.

===SANS 10400-O (2011)===
{{Expand}}

==Air-Conditioning, Ventilation and COVID-19==
It is important to differentiate between ventilation and air-conditioning when discussion indoor contamination. When the term ventilation is used, it describes any system that induces decontaminated, fresh or outdoor-air to enter a space by the application of supply or extraction systems. Diluting ventilation is the most commonly used regime. Other modes of contaminant removal include displacement and local exhaust ventilation systems, each of which requires its own nuanced discussion as they pertain to infection control.

Air-conditioning in contrast, refers to only the mechanical cooling or heating system, sometimes installed directly in a space (Spit-AC), to offer thermal comfort and sometimes humidity control. In-room air-conditioning systems that circulate air directly within a space with no dilution or extraction can directly offer no reduction in airborne contaminant levels. In some instances they can even assist in the distribution of contaminants.

Openable windows can be considered as ventilation apertures and, in most cases, offer highly effective ventilation. Unfortunately, this is sometimes at the expense of indoor comfort. Even though long range droplet transmission of SARS-CoV-2 is relatively low in comparison to short range transmission, encouraging occupants to open windows will reduce that risk. Allowing occupants to use air-conditioning to either heat or cool a space while windows are open can improve levels of open window compliance which is more important than limiting AC use for reducing long range transmission. An additional strategy to both improve open window compliance and reduce AC usage would be to relax strict corporate dress codes as this can improve thermal comfort levels seasonally.

==Engineering Response==
Ventilation society guidance understandably bears the risk of being biased toward over-prescribing solutions over which engineers have the greatest understanding and control. It is within this context that the valuable guidance published online by REHVA and ASHRAE should be considered. Revamping existing ventilation systems in resource-constrained healthcare settings to meet admittedly overly-cautious guidance should not be conducted without an informed investment case.
"In these resource limited settings, it needs to be carefully considered whether resources are allocated to clinical capacity or to possibly unnecessary ventilation when the benefits of these criteria may be comparatively marginal."

Without good viability studies of the viral particles found in air or ventilation systems, no firm guidance can be offered regarding the rate of reduction for SARS-CoV-2 viability with time and distance. Until that time it would be prudent to assume that the virus should only be considered as airborne under special and rare conditions, based on the guidance of the WHO, and these conditions should be avoided. This would determine that we have different filtration and ventilation approaches between COVID-ICUs, general indoor public spaces and spaces with a potential for high density occupation. Engineers should not be tempted to assume or argue that all indoor spaces bear the same risk profile.

For high-risk spaces it may be prudent to implement temporary measures to limit transmission risk to the minimum possible. In order of priorities, engineering interventions include:

#decongest indoor spaces to the minimum possible occupancy levels
#open windows to outside when occupational health, safety and security are not compromised
#increase HVAC fresh air rates to maximum possible levels
#reduce HVAC recirculation levels to minimum possible levels
#flush buildings with fresh air before and after daily occupancy

The following matrix is intended to guide our design responses for a sample of space types
{| class="wikitable"
|+Risk Response Matrix
!Space Type
!Risk
!Initial Risk
!Engineering Response
!Residual Risk
|-
| rowspan="2" |ICU
|Transmission in ICU
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Low
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Where high risks are associated with adjacent spaces, ventilate ICU in accordance with IUSS Guidelines for Airborne Precaution Rooms
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |Surgeries
|Transmission in Theatre
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs,
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Moderate
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Surgeries on identified COVID-19 patients in negative pressure theatres only.
##No recirculation to adjacent spaces (for negative pressure theatres)
##Ensure compliance with contact, droplet and airborne precautions for staff
##Where high risks are associated with adjacent spaces, ventilate the operating room in accordance with IUSS Guidelines for Airborne Precaution Rooms or sepsis theatres
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |COVID Wards
|Transmission within COVID-19 Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for general wards
#Keep available windows open when safe and secure
#Ensure compliance with contact, droplet and airborne precautions
|Low
|-
|Transmission to Adjacent spaces
|High
| 

#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
##Increase ventilation rates in adjacent areas (passages)
##Positive pressure relative to COVID wards
##Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
##Extraction systems to discharge safely at high-level
|Low
|-
|General wards
|Transmission within and from Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for General Wards
|Low
|-
|Emergency centre
|Transmission within EC
|High
|
#Reduce number of occupants to only essential staff and caregivers
#Screen and fast-track patients with respiratory illness symptoms
#Isolate persons under investigation for COVID-19
##Isolation rooms ventilated in accordance with IUSS guidance for airborne precaution rooms
|Moderate
|-
|Hospital Waiting Areas
|Transmission within waiting room
|High
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with IUSS Guidelines for Waiting Areas
|Moderate
|-
|Other public waiting spaces
|Transmission within waiting room
|Moderate
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with Building Regulations
|Moderate
|}

===Conclusion===
Therefore, assuming ventilation systems in South Africa have been designed in accordance with the IUSS guidance, there should be little reason to change their configuration or pressurization unless general areas are repurposed as airborne precaution rooms. Risk assessments should be conducted for ICUs and COVID-19 wards immediately adjacent to public waiting areas or other high traffic areas, with corrective actions including but not limited to reducing occupancy times and rates for these areas and adjusting distancing rules.

 
----

==Notes and References==
[[Category:Reference Desk]]
[[Category:COVID-19]]
[[Category:ICU]]
<references />
[[Category:ASHRAE]]
[[Category:REHVA]]
[[Category:IUSS]]
[[Category:Airborne Infection control]]
[[Category:Airborne Contamination Control]]

Ventilation and COVID-19

2020-07-21T07:31:33Z

Peta: /* Guangzhou Restaurant Outbreak (2020) */

[[Category:COVID-19]]
[[Category:Crosscutting Issues]]

==Context==
This article aims to to contextualize COVID-19 related ventilation guidelines in a field of developing clinical evidence. This is done with the hope of empowering the reader to scrutinize proposed interventions within this context and employ appropriate and efficient solutions. The information and guidance in this article is the developing opinion of the author and does not represent any regulatory or institutional mandate or authority. The evidence supporting this opinion is evolving and therefore the opinion is similarly subject to change. The reader is encouraged to return to this article frequently to review any changes additions or updates highlighted in the history tab above.

Discussion and contributions are similarly welcomed in the discussion tab above.[https://thehillside.info/index.php?title=Talk:Ventilation_and_COVID-19#section1]

==Background==

===Transmission routes===
SARS-CoV-2 has caused many to revisit their understanding of droplet and airborne transmission. These two transmission mechanisms form a continuum, but the following is generally accepted:

*''Infectious'' particles <5μm in size can remain suspended and viable for many hours and these contribute to the risk of '''airborne transmission'''.
*'''Droplet transmission''' involves larger particles which can also spread through the air for some distance, but the range of transmission is generally considered to be less than 2 meters where after particles fall out of the breathing zone. It is important to remember that within this 2 m distance these larger droplets are essentially 'airborne' and diluting ventilation systems have little effect on reducing the risk of near-range droplet transmission<ref>Liu, L., Li, Y., Nielsen, P. V., Wei, J. & Jensen, R. L. Short-range airborne transmission of expiratory droplets between two people. Indoor Air 1–11 (2016) doi:10.1111/ina.12314.</ref>.

Droplet precautions, therefore, include standard precautions like PPE, hand washing and distancing, while airborne precautions include negative pressure isolation, respiratory protection, special exhaust or filtration regimes, etc.

Diseases seldom obey only one mode of transmission (obligatory transmission) but often have preferences (preferential transmission) while occasionally exploiting circumstances which provide rare opportunities for transmission (opportunistic routes). SARS-COV-2 is understood to be '''preferentially droplet and contact spread''' (a form of droplet spread where droplets can settle on fomites) with possible rare and opportunistic airborne spread, although an extensive outbreak review revealed no indication of airborne spread<ref>https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>.

===Airborne Transmission===
There is still little strong evidence of common long-range airborne transmission in the sense of droplet nucleation, as with TB and measles<ref>World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) 16-24 February 2020 [Internet]. Geneva: World Health Organization; 2020 Available from: [https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf]</ref>. Where evidence of airborne transmission has been reported, this can be seen in the context of opportunistic long-range droplet spread<ref> Wenzhao Chen, Nan Zhang, Jianjian Wei, Hui-LingYen, and Yuguo Li, “Short-range airborne route dominates exposure of respiratory infection during close contact,” medRxiv preprint, https://doi.org/10.1101/2020.03.16.20037291</ref>. A discussion contextualizing the reported cases of airborne transmission is discussed below.

====van Doremalen et al (NEMJ 2020)====
The van Doremalen SARS-CoV-2 survival study<ref name="van Doremalen">Neeltje van Doremalen, Trenton Bushmaker, Dylan H. Morris, Myndi G. Holbrook, Amandine Gamble, Brandi N. Williamson, Azaibi Tamin, Jennifer L. Harcourt, Natalie J. Thornburg, Susan I. Gerber, James O. LloydSmith, Emmie de Wit, and Vincent J. Munster, “Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1,” The New England Journal of Medicine (2020), DOI: 10.1056/NEJMc2004973 [https://www.nejm.org/doi/pdf/10.1056/NEJMc2004973?articleTools=true]</ref> is often incorrectly reported to have shown that SARS-CoV-2 can remain viable in air for extended periods. No evidence for long range airborne viability has yet been found outside of lab settings. SARS-CoV-2 virus found dispersed at long range has not been cultured to prove viability and many studies have failed to detect it directly in air in quantities substantial enough to culture<ref>Faridi, S. et al. A field indoor air measurement of SARS-CoV-2 in the patient rooms of the largest hospital in Iran. Sci. Total Environ. 725, 1–5 (2020).</ref><ref>Liu, Y. et al. Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals. Nature (2020) doi:10.1038/s41586-020-2271-3.</ref>. Correlations between culture viability, particle size and the real world infectious quantum were not described in this study<ref name="van Doremalen" /> as it was not the study's intention to claim COVID-19 was airborne. A more recent pre-publication article has made similar findings<ref>Fears SC, Klimstra WB, Duprex P, Hartman A, Weaver SC, Plante KS, et al. Persistence of severe acute respiratory syndrome coronavirus 2 in aerosol suspensions. Emerg Infect Dis. 2020 Sep [''date cited'']. <nowiki>https://doi.org/10.3201/eid2609.201806</nowiki></ref> but this has significant problems with equipment standardization and repeatability. More importantly, similar lab studies have also demonstrated a 3h airborne survival for viral strains such as Ebola not considered to be airborne<ref>Robert Comparison of the Aerosol Stability of 2 Strains of Zaire ebolavirus From the 1976 and 2013 Outbreaks Robert J. Fischer, Trenton Bushmaker, Seth Judson, Vincent J. Munster
J Infect Dis. 2016 Oct 15; 214(Suppl 3): S290–S293. Published online 2016 Oct 4. doi: 10.1093/infdis/jiw193 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5050463/</ref>. This makes the direct application of this lab study in real-world settings problematic. Therefore, the understanding of the mechanisms of COVID-19 transmission is still largely reliant on what is understood of SARS (SARS-CoV-1)<ref>Isao Arita, Kazunobu Kojima, and Miyuki Nakane, “Transmission of severe acute respiratory syndrome,” Emerging. Infectious Diseases 9 No. 9 (2003):1183-84, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016764/].</ref>.

====Guangzhou Restaurant Outbreak (2020)====
[[File:Guangzhou Restaurant COVID-19 2020.png|thumb|Plan of COVID-19 outbreak in Guangzhou Restaurant 2020<ref name=":0">Lu, J., Gu, J., Li, K., Xu, C., Su, W., Lai, Z....Yang, Z. (2020). COVID-19 Outbreak Associated with Air Conditioning in Restaurant, Guangzhou, China, 2020. ''Emerging Infectious Diseases'', ''26''(7), 1628-1631. <nowiki>https://dx.doi.org/10.3201/eid2607.200764</nowiki>.[https://wwwnc.cdc.gov/eid/article/26/7/20-0764_article]</ref>]]
The 2020 outbreak of COVID-19 in a restaurant in Guangzhou<ref name=":0" /> raises some important questions around the airborne spread of the disease. This study shows that the transmission range of COVID-19 may exceed the generally prescribed separation distance of 1m under certain conditions, but fails to do so convincingly. Confounding issues that are not addressed adequately in the articles conclusion include:

*the high probability of asymptomatic or pre-symptomatic spread of the virus from members of the index case's family<ref>How Coronavirus Infected Some, but Not All, in a Restaurant, Chang, K (2020) https://www.nytimes.com/2020/04/20/health/airflow-coronavirus-restaurants.html</ref>
*the possibility of onward transmission within family groups after the restaurant exposure is acknowledged but dismissed without discussion
*the difference in exposure times<ref>https://english.elpais.com/spanish_news/2020-06-17/an-analysis-of-three-covid-19-outbreaks-how-they-happened-and-how-they-can-be-avoided.html</ref> between tables (C-B )and (E-F) is not adequately addressed
*The overcrowded and under ventilated conditions in the restaurant.

This is a seminal event in the study of SARS-CoV-2 transmission, but we should be cautious to use it a clear evidence if airborne transmission where similar events are not widespread by now.

===='''South Korea Call Centre Outbreak 2020'''====
[[File:South Korea Call Centre Outbreak COVID-19 2020.png|thumb|Floor plan of South Korea Call Centre Outbreak COVID-19 2020]]
In this pre-publication report, the outbreak in a call-centre on the 11th story of a South Korean office block<ref>Park SY, Kim YM, Yi S, Lee S, Na BJ, Kim CB, et al. Coronavirus disease outbreak in call center, South Korea. Emerg Infect Dis. 2020 Aug [''date cited'']. <nowiki>https://doi.org/10.3201/eid2608.201274</nowiki></ref> offer some extraordinary insights but leaves many questions open. The distribution of the attacks is alarming in the call centre room, but is significantly reduced in adjacent room on the same floor.

The following is a summary of the findings:

*It appears as if the outbreak followed physical compartmentalization and not HVAC zoning although an HVAC plan of the building was not discussed.
*It is clear is that COVID-19 is exceptionally contagious in crowded office settings.
*Lobbies and lifts contributed little to spread
*Exposure time correlated with transmission risk

Questions that remain:

*HVAC zoning or an HVAC plan of the building was not discussed
*Ratios of male and female cases would have offered insight into the roles of bathrooms in COVID-19 spread
*A review of vertical transport characteristics may have offered insight into the vertical distribution of cases through the building

===Aircraft Transmission Studies===
SARS and COVID-19 Outbreaks on commercial aircraft have proven to be remarkedly rare. This may be due to the high ventilation rates<ref>Mangili, A., & Gendreau, M. A. (2005). Transmission of infectious diseases during commercial air travel. ''Lancet (London, England)'', ''365''(9463), 989–996. <nowiki>https://doi.org/10.1016/S0140-6736(05)71089-8</nowiki></ref>. Studies tracing contacts on flights seem to show multiple cases of very low to zero transmission rates with the transmission events raising disproportional alarm<ref name=":3">Olsen et al, N Engl J Med 2003; 349:2416-2422Transmission of the Severe Acute Respiratory Syndrome on Aircraft, DOI: 10.1056/NEJMoa031349 [https://www.nejm.org/doi/full/10.1056/nejmoa031349]</ref><ref>CMAJ 2020 April 14;192:E410. doi: 10.1503/cmaj.75015 [https://www.cmaj.ca/content/cmaj/192/15/E410.full.pdf]</ref>. The context of the scope of aircraft outbreak findings highlights the role ventilation has in creating safe environments, but similarly reveals the low risk levels associated with airborne transmission of SARS or COVID-19

====Amoy Gardens SARS Outbreak (2003)<ref name=":1">McKinney KR, Gong YY, Lewis TG. Environmental transmission of SARS at Amoy Gardens. ''J Environ Health''. 2006;68(9):26-52.</ref>====
Studies, which indicate the Amoy Gardens building's SARS outbreaks' transmission was via the airborne route<ref name=":1" />, commonly reference the prevailing wind between buildings. It should be noted that, since these buildings are about 60m apart the environmental dilution and concentration decay effects are so strong it is not feasible that an infectious dose persists at that range. Similarly, the possibility that air can commute out of one window and into another needs to account for these dilution effects before assumptions of transmission can be drawn. These studies do not sufficiently account for dilution, infectious doses and pathogen survival rates. A more feasible hypothesis is that the Amoy Gardens intra-building spread was through re-aerosolisation of contaminated waste water coming from the faulty plumbing system. Similar outbreaks have more recently been found<ref name=":2">Bhowmick, G.D., Dhar, D., Nath, D. et al. Coronavirus disease 2019 (COVID-19) outbreak: some serious consequences with urban and rural water cycle. npj Clean Water 3, 32 (2020). https://doi.org/10.1038/s41545-020-0079-1</ref>

====Other studies====
Studies which have found real-world SARS-CoV-2 in air, ducting and on extraction fans have so far failed to prove that the virus found was still viable<ref>Santarpia et al, “Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center,. medRxiv preprint (2020), [https://doi.org/10.1101/2020.03.23.20039446]</ref><ref>Po Ying Chia et al, 2020 (Preprint) “Detection of Air and Surface Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in Hospital Rooms of Infective Patients,” medRxiv preprint (2020), https://doi.org/10.1101/2020.03.29.20046557 [https://www.medrxiv.org/content/10.1101/2020.03.29.20046557v2.full.pdf]</ref>. Air sampling studies have failed to detect viable SARS-CoV-2 <ref>Ong SWX, Tan YK, Chia PY, et al. Air, Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient. ''JAMA.'' 2020;323(16):1610–1612. doi:10.1001/jama.2020.3227</ref>.

It has been suggested that high temperature and humidity would reduce the spread of the virus<ref>Chin, A. W. H. et al. Stability of SARS-CoV-2 in different environmental conditions. The Lancet Microbe 0–4 (2020) doi:10.1016/s2666-5247(20)30003-3.</ref><ref>Pyankov, O. V., Bodnev, S. A., Pyankova, O. G. & Agranovski, I. E. Survival of aerosolized coronavirus in the ambient air. J. Aerosol Sci. 115, (2018).</ref>. The temperature ranges suggested (>50°C) are beyond what anyone could endure in an ICU but the humidity ranges of between 40-60% are achievable. The high humidity slows the nucleation of the viral droplet and increases its settling speed, thereby reducing its range.
====High Risk Settings (ICU)====
Much of the work being done to understand the transmission mechanism of COVID-19 is focused on community transmission. It is important to remember that transmission risk in an ICU will not be the same as in homes and workplaces. The conditions and procedures in ICUs could promote transmission - see WHO 2020 below<ref name="WHO 2020">WHO 2020, Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>. Firstly, in a COVID ICU unit, the contamination source strength is much higher than other spaces since infected patients are congregated there. These are presumably ill patients with high viral shedding. Secondly, procedures like intubation are understood to release high quantities of aerosolized particles, unlike with general talking or coughing. Additionally, viral shedding through talking and coughing can be more readily mitigated than from intubation.

===Fecal-Oral Transmission===
Fecal oral route of transmission is acknowledged for COVID-19<ref>Pan Y, Zhang D, Yang P, Poon LLM, Wang Q. Viral load of SARS-CoV-2 in clinical samples. Lancet Infect Dis. 2020;20(4):411-2.</ref> and considerations for waste water management are discussed [[SARS-CoV-2 is found in faecal matter|here]] and [https://doi.org/10.1016/j.scitotenv.2020.139076 here]<ref>Kitajima et al,SARS-CoV-2 in wastewater: State of the knowledge and research needs,Science of The Total Environment,Volume 739,2020,139076,ISSN 0048-9697,<nowiki>https://doi.org/10.1016/j.scitotenv.2020.139076</nowiki></ref>. This transmission route indirectly affects ventilation system design as special consideration should be given to common scenarios where the aerosolisation of contaminated wastewater is a possibility such as in bathrooms, sluice rooms and slurry pumping. These spaces should be well-ventilated and kept under negative pressure relative to adjacent spaces.

==Institutional Guidance==
===WHO===
The WHO's advice regarding SARS-CoV-2 transmission during clinical interventions is as follows:
''"In the context of COVID-19, airborne transmission may be possible in specific circumstances and settings in which procedures or support treatments that generate aerosols are performed; i.e., endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, turning the patient to the prone position, disconnecting the patient from the ventilator, non-invasive positive-pressure ventilation, tracheostomy, and cardiopulmonary resuscitation."'' - WHO 2020<ref name="WHO 2020" /> 

While the WHO's position acknowledges the increased risk of transmission in overcrowded and under-ventilated spaces, the appropriate response is not to increase prescribed general ventilation rates, but rather to avoid overcrowding and maintain ventilation systems correctly.
===US-CDC===
The CDC's advice regarding SARS-CoV-2 transmission is still nearly identical to its guidance for SARS-CoV-1:
''"The primary transmission of COVID-19 is from person-to-person through respiratory droplets. These droplets are released when someone with COVID-19 sneezes or coughs. COVID-19 can also be spread when you are in close contact with someone who is sick (e.g., shaking hands or talking). A physical distance of at least 1 meter (3ft) between persons is suggested by the World Health Organization (WHO) to avoid infection, although some WHO member states have recommended maintaining greater distances whenever possible. Respiratory droplets can land on objects or surfaces around the person when they cough or talk, and people can then become infected with COVID-19 from touching these objects or surfaces and then touching their eyes, nose or mouth. Recent data suggests that there can be transmission of COVID-19 through droplets of those with mild symptoms or those who do not feel ill"'' <ref>https://www.cdc.gov/sars/about/faq.html</ref><ref>https://www.cdc.gov/sars/about/faq.html</ref>

The US-CDC's recommendations regarding inpatient accommodation for SARS includes the comment,
"Experience in some settings in Taiwan and Toronto demonstrated that cohorting SARS patients, without use of AIIRs, effectively interrupted transmission"<ref>US-CDC,2005, https://www.cdc.gov/sars/guidance/i-infection/healthcare.html</ref>
The CDC's guidance is consistent with the full context of hierarchical risk-based infection control and is suitably cognizant of variously resourced settings.
"Airborne Infection Isolation Rooms (AIIRs) (See definition of AIIR in appendix) should be reserved for patients who will be undergoing aerosol generating procedures (See Aerosol Generating Procedures Section)."<ref>Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (updated July 9, 2020)[https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html]</ref>
This nuanced approach is difficult to tease out of the guidance from engineering societies.

===ASHRAE===
While the US-CDC and WHO maintains that the airborne transmission is possible but not common or of primary concern, ASHRAE (being an association dedicated to ventilation engineering) focuses on the airborne component.
"Transmission of SARS-CoV-2 through the air is sufficiently likely that airborne exposure to the virus should be controlled. Changes to building operations, including the operation of heating, ventilating, and air-conditioning systems, can reduce airborne exposures"<ref>Q: Does ASHRAE’s guidance agree with guidance from WHO and CDC?[https://www.ashrae.org/file%20library/technical%20resources/covid-19/does-ashrae-s-guidance-agree-with-guidance-from-who-and-cdc.pdf]</ref>
ASHRAE makes useful distinctions between guidance for healthcare<ref>ASHRAE healthcare C19 guidance (ASHRAE 2020) [https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-healthcare-c19-guidance.pdf]</ref>, residential <ref>ASHRAE residential c19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-residential-c19-guidance.pdf]</ref><ref>COVID 19 guidance for multifamily building owners-managers (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/covid-19-guidance-for-multifamily-building-owners_managers.pdf]</ref>, commercial <ref>ASHRAE commercial C19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-commercial-c19-guidance.pdf]</ref> and schools<ref>ASHRAE Schools C19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-schools-c19-guidance.pdf</ref>, but doesn't significantly address risk categories specifically in healthcare or resource limited settings.
===REHVA===
REHVA's temporary guidance is limited to commercial and public buildings<ref>REHVA COVID-19 guidance document, April 3, 2020[https://www.rehva.eu/fileadmin/user_upload/REHVA_COVID-19_guidance_document_ver2_20200403_1.pdf]</ref>. Similar to ASHRAE, REHVA focusses on engineering controls for airborne transmission. REHVA acknowledges importance of droplet precautions and the lack of quality evidence for airborne transmission, but draws the conclusion that SARS-CoV-2 RNA found in ventilation ducting implies airborne transmission, even though these real world studies have not yet proven viability of these particles. REHVA also draws the airborne conclusion from the van Doremalen study<ref name="van Doremalen" /> out of its intended comparative context.

===IUSS (2014)===
The [[Infrastructure_Unit_System_Support|IUSS]] Building Engineering Services Guidelines<ref>Building Engineering Services (2014)[https://iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-services]</ref>, which is mandated for new buildings by provincial departments of health by reference in Government Notice R116<ref>Government Notice R116 (17 Feb 2014)[https://iussonline.co.za/docman/gazettes/116-notice-37348/file]</ref>, describes risk based ventilation criteria which are broadly appropriate for COVID-19, if not excessive. This guideline was developed with control measures for the current TB epidemic in mind. These measures would be more than appropriate for most healthcare spaces. The guidance recommends no recirculation of air between theatres and adjacent spaces but does not prohibit cascading from surgeries to adjacent spaces. Therefore, confirmed COVID-19 patients should only be treated in negative pressure operating rooms that comply with the guidelines.

===SANS 10400-O (2011)===
{{Expand}}

==Air-Conditioning, Ventilation and COVID-19==
It is important to differentiate between ventilation and air-conditioning when discussion indoor contamination. When the term ventilation is used, it describes any system that induces decontaminated, fresh or outdoor-air to enter a space by the application of supply or extraction systems. Diluting ventilation is the most commonly used regime. Other modes of contaminant removal include displacement and local exhaust ventilation systems, each of which requires its own nuanced discussion as they pertain to infection control.

Air-conditioning in contrast, refers to only the mechanical cooling or heating system, sometimes installed directly in a space (Spit-AC), to offer thermal comfort and sometimes humidity control. In-room air-conditioning systems that circulate air directly within a space with no dilution or extraction can directly offer no reduction in airborne contaminant levels. In some instances they can even assist in the distribution of contaminants.

Openable windows can be considered as ventilation apertures and, in most cases, offer highly effective ventilation. Unfortunately, this is sometimes at the expense of indoor comfort. Even though long range droplet transmission of SARS-CoV-2 is relatively low in comparison to short range transmission, encouraging occupants to open windows will reduce that risk. Allowing occupants to use air-conditioning to either heat or cool a space while windows are open can improve levels of open window compliance which is more important than limiting AC use for reducing long range transmission. An additional strategy to both improve open window compliance and reduce AC usage would be to relax strict corporate dress codes as this can improve thermal comfort levels seasonally.

==Engineering Response==
Ventilation society guidance understandably bears the risk of being biased toward over-prescribing solutions over which engineers have the greatest understanding and control. It is within this context that the valuable guidance published online by REHVA and ASHRAE should be considered. Revamping existing ventilation systems in resource-constrained healthcare settings to meet admittedly overly-cautious guidance should not be conducted without an informed investment case.
"In these resource limited settings, it needs to be carefully considered whether resources are allocated to clinical capacity or to possibly unnecessary ventilation when the benefits of these criteria may be comparatively marginal."

Without good viability studies of the viral particles found in air or ventilation systems, no firm guidance can be offered regarding the rate of reduction for SARS-CoV-2 viability with time and distance. Until that time it would be prudent to assume that the virus should only be considered as airborne under special and rare conditions, based on the guidance of the WHO, and these conditions should be avoided. This would determine that we have different filtration and ventilation approaches between COVID-ICUs, general indoor public spaces and spaces with a potential for high density occupation. Engineers should not be tempted to assume or argue that all indoor spaces bear the same risk profile.

For high-risk spaces it may be prudent to implement temporary measures to limit transmission risk to the minimum possible. In order of priorities, engineering interventions include:

#decongest indoor spaces to the minimum possible occupancy levels
#open windows to outside when occupational health, safety and security are not compromised
#increase HVAC fresh air rates to maximum possible levels
#reduce HVAC recirculation levels to minimum possible levels
#flush buildings with fresh air before and after daily occupancy

The following matrix is intended to guide our design responses for a sample of space types
{| class="wikitable"
|+Risk Response Matrix
!Space Type
!Risk
!Initial Risk
!Engineering Response
!Residual Risk
|-
| rowspan="2" |ICU
|Transmission in ICU
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Low
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Where high risks are associated with adjacent spaces, ventilate ICU in accordance with IUSS Guidelines for Airborne Precaution Rooms
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |Surgeries
|Transmission in Theatre
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs,
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Moderate
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Surgeries on identified COVID-19 patients in negative pressure theatres only.
##No recirculation to adjacent spaces (for negative pressure theatres)
##Ensure compliance with contact, droplet and airborne precautions for staff
##Where high risks are associated with adjacent spaces, ventilate the operating room in accordance with IUSS Guidelines for Airborne Precaution Rooms or sepsis theatres
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |COVID Wards
|Transmission within COVID-19 Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for general wards
#Keep available windows open when safe and secure
#Ensure compliance with contact, droplet and airborne precautions
|Low
|-
|Transmission to Adjacent spaces
|High
| 

#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
##Increase ventilation rates in adjacent areas (passages)
##Positive pressure relative to COVID wards
##Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
##Extraction systems to discharge safely at high-level
|Low
|-
|General wards
|Transmission within and from Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for General Wards
|Low
|-
|Emergency centre
|Transmission within EC
|High
|
#Reduce number of occupants to only essential staff and caregivers
#Screen and fast-track patients with respiratory illness symptoms
#Isolate persons under investigation for COVID-19
##Isolation rooms ventilated in accordance with IUSS guidance for airborne precaution rooms
|Moderate
|-
|Hospital Waiting Areas
|Transmission within waiting room
|High
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with IUSS Guidelines for Waiting Areas
|Moderate
|-
|Other public waiting spaces
|Transmission within waiting room
|Moderate
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with Building Regulations
|Moderate
|}

===Conclusion===
Therefore, assuming ventilation systems in South Africa have been designed in accordance with the IUSS guidance, there should be little reason to change their configuration or pressurization unless general areas are repurposed as airborne precaution rooms. Risk assessments should be conducted for ICUs and COVID-19 wards immediately adjacent to public waiting areas or other high traffic areas, with corrective actions including but not limited to reducing occupancy times and rates for these areas and adjusting distancing rules.

 
----

==Notes and References==
[[Category:Reference Desk]]
[[Category:COVID-19]]
[[Category:ICU]]
<references />
[[Category:ASHRAE]]
[[Category:REHVA]]
[[Category:IUSS]]
[[Category:Airborne Infection control]]
[[Category:Airborne Contamination Control]]

Ventilation and COVID-19

2020-07-14T16:20:56Z

Peta: /* A Note on Amoy Gardens SARS studies[18] */

[[Category:COVID-19]]
[[Category:Airborne Contamination Control]]
[[Category:Crosscutting Issues]]

==Context==
This article aims to to contextualize COVID-19 related ventilation guidelines in a field of developing clinical evidence. This is done with the hope of empowering the reader to scrutinize proposed interventions within this context and employ appropriate and efficient solutions. The information and guidance in this article is the developing opinion of the author and does not represent any regulatory or institutional mandate or authority. The evidence supporting this opinion is evolving and therefore the opinion is similarly subject to change. The reader is encouraged to return to this article frequently to review any changes additions or updates highlighted in the history tab above.

Discussion and contributions are similarly welcomed in the discussion tab above.

==Background==

===Transmission routes===
SARS-CoV-2 seems to have caused many to rethink their understanding of droplet and airborne transmission. These two transmission mechanisms form a continuum, but the following is generally accepted:

*''Infectious'' particles <5μm in size can remain suspended and viable for many hours and these contribute to the risk of '''airborne transmission'''.
*'''Droplet transmission''' involves larger particles which can also spread through the air for some distance, but the range of transmission is generally considered to be less than 2 meters where after particles fall out of the breathing zone. It is important to remember that within this 2 m distance these larger droplets are essentially 'airborne' and diluting ventilation systems have little effect on reducing the risk of near-range droplet transmission<ref>Liu, L., Li, Y., Nielsen, P. V., Wei, J. & Jensen, R. L. Short-range airborne transmission of expiratory droplets between two people. Indoor Air 1–11 (2016) doi:10.1111/ina.12314.</ref>.

Droplet precautions, therefore, include standard precautions like PPE, hand washing and distancing, while airborne precautions include negative pressure isolation, respiratory protection, special exhaust or filtration regimes, etc.

Diseases seldom obey only one mode of transmission (obligatory transmission) but often have preferences (preferential transmission) while occasionally exploiting circumstances which provide rare opportunities for transmission (opportunistic routes). SARS-COV-2 is understood to be '''preferentially droplet and contact spread''' (a form of droplet spread where droplets can settle on fomites) with possible rare and opportunistic airborne spread, although an extensive outbreak review revealed no indication of airborne spread<ref>https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>.

===Airborne Transmission===
There is still little strong evidence of common long-range airborne transmission in the sense of droplet nucleation, as with TB and measles<ref>World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) 16-24 February 2020 [Internet]. Geneva: World Health Organization; 2020 Available from: [https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf]</ref>. Where evidence of airborne transmission has been reported, this can be seen in the context of opportunistic long-range droplet spread<ref> Wenzhao Chen, Nan Zhang, Jianjian Wei, Hui-LingYen, and Yuguo Li, “Short-range airborne route dominates exposure of respiratory infection during close contact,” medRxiv preprint, https://doi.org/10.1101/2020.03.16.20037291</ref>. A discussion contextualizing the reported cases of airborne transmission is discussed below. 

The van Doremalen SARS-CoV-2 survival study<ref name="van Doremalen">Neeltje van Doremalen, Trenton Bushmaker, Dylan H. Morris, Myndi G. Holbrook, Amandine Gamble, Brandi N. Williamson, Azaibi Tamin, Jennifer L. Harcourt, Natalie J. Thornburg, Susan I. Gerber, James O. LloydSmith, Emmie de Wit, and Vincent J. Munster, “Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1,” The New England Journal of Medicine (2020), DOI: 10.1056/NEJMc2004973 [https://www.nejm.org/doi/pdf/10.1056/NEJMc2004973?articleTools=true]</ref> is often incorrectly reported to have shown that SARS-CoV-2 can remain viable in air for extended periods. No evidence for long range airborne viability has yet been found outside of lab settings. SARS-CoV-2 virus found dispersed at long range has not been cultured to prove viability and many studies have failed to detect it directly in air in quantities substantial enough to culture<ref>Faridi, S. et al. A field indoor air measurement of SARS-CoV-2 in the patient rooms of the largest hospital in Iran. Sci. Total Environ. 725, 1–5 (2020).</ref><ref>Liu, Y. et al. Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals. Nature (2020) doi:10.1038/s41586-020-2271-3.</ref>. Correlations between culture viability, particle size and the real world infectious quantum were not described in this study<ref name="van Doremalen" /> as it was not the study's intention to claim COVID-19 was airborne. A more recent pre-publication article has made similar findings<ref>Fears SC, Klimstra WB, Duprex P, Hartman A, Weaver SC, Plante KS, et al. Persistence of severe acute respiratory syndrome coronavirus 2 in aerosol suspensions. Emerg Infect Dis. 2020 Sep [''date cited'']. <nowiki>https://doi.org/10.3201/eid2609.201806</nowiki></ref> but this has significant problems with equipment standardization and repeatability. More importantly, similar lab studies have also demonstrated a 3h airborne survival for viral strains such as Ebola not considered to be airborne<ref>Robert Comparison of the Aerosol Stability of 2 Strains of Zaire ebolavirus From the 1976 and 2013 Outbreaks Robert J. Fischer, Trenton Bushmaker, Seth Judson, Vincent J. Munster
J Infect Dis. 2016 Oct 15; 214(Suppl 3): S290–S293. Published online 2016 Oct 4. doi: 10.1093/infdis/jiw193 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5050463/</ref>. This makes the direct application of this lab study in real-world settings problematic.

Studies which have found real-world SARS-CoV-2 in air, ducting and on extraction fans have so far failed to prove that the virus found was still viable<ref>Santarpia et al, “Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center,. medRxiv preprint (2020), [https://doi.org/10.1101/2020.03.23.20039446]</ref><ref>Po Ying Chia et al, 2020 (Preprint) “Detection of Air and Surface Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in Hospital Rooms of Infective Patients,” medRxiv preprint (2020), https://doi.org/10.1101/2020.03.29.20046557 [https://www.medrxiv.org/content/10.1101/2020.03.29.20046557v2.full.pdf]</ref>.

Therefore, the understanding of the mechanisms of COVID-19 transmission is still largely reliant on what is understood of SARS (SARS-CoV-1)<ref>Isao Arita, Kazunobu Kojima, and Miyuki Nakane, “Transmission of severe acute respiratory syndrome,” Emerging. Infectious Diseases 9 No. 9 (2003):1183-84, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016764/].</ref>

 It has been suggested that high temperature and humidity would reduce the spread of the virus<ref>Chin, A. W. H. et al. Stability of SARS-CoV-2 in different environmental conditions. The Lancet Microbe 0–4 (2020) doi:10.1016/s2666-5247(20)30003-3.</ref><ref>Pyankov, O. V., Bodnev, S. A., Pyankova, O. G. & Agranovski, I. E. Survival of aerosolized coronavirus in the ambient air. J. Aerosol Sci. 115, (2018).</ref>. The temperature ranges suggested (>50°C) are beyond what anyone could endure in an ICU but the humidity ranges of between 40-60% are achievable. The high humidity slows the nucleation of the viral droplet and increases its settling speed, thereby reducing its range.
====High Risk Settings (ICU)====
Much of the work being done to understand the transmission mechanism of COVID-19 is focused on community transmission. It is important to remember that transmission risk in an ICU will not be the same as in homes and workplaces. The conditions and procedures in ICUs could promote transmission - see WHO 2020 below<ref name="WHO 2020">WHO 2020, Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>. Firstly, in a COVID ICU unit, the contamination source strength is much higher than other spaces since infected patients are congregated there. These are presumably ill patients with high viral shedding. Secondly, procedures like intubation are understood to release high quantities of aerosolized particles, unlike with general talking or coughing. Additionally, viral shedding through talking and coughing can be more readily mitigated than from intubation.

===Fecal-Oral Transmission===
Fecal oral route of transmission is acknowledged for COVID-19<ref>Pan Y, Zhang D, Yang P, Poon LLM, Wang Q. Viral load of SARS-CoV-2 in clinical samples. Lancet Infect Dis. 2020;20(4):411-2.</ref> and considerations for waste water management are discussed [[SARS-CoV-2 is found in faecal matter|here]] and [https://doi.org/10.1016/j.scitotenv.2020.139076 here]<ref>Kitajima et al,SARS-CoV-2 in wastewater: State of the knowledge and research needs,Science of The Total Environment,Volume 739,2020,139076,ISSN 0048-9697,<nowiki>https://doi.org/10.1016/j.scitotenv.2020.139076</nowiki></ref>

This transmission route indirectly affects ventilation system design as special consideration should be given to common scenarios where the aerosolisation of contaminated wastewater is a possibility such as in bathrooms, sluice rooms and slurry pumping. These spaces should be well-ventilated and kept under negative pressure relative to adjacent spaces.

====A Note on ''Amoy Gardens'' SARS studies<ref>McKinney KR, Gong YY, Lewis TG. Environmental transmission of SARS at Amoy Gardens. ''J Environ Health''. 2006;68(9):26-52.</ref>====
Studies, which indicate the Amoy Gardens building's SARS outbreaks' transmission was via the airborne route, commonly reference the prevailing wind between buildings. It should be noted that, since these buildings are about 60m apart the environmental dilution and concentration decay effects are so strong it is not feasible that an infectious dose persists at that range. Similarly, the possibility that air can commute out of one window and into another needs to account for these dilution effects before assumptions of transmission can be drawn. These studies do not sufficiently account for dilution, infectious doses and pathogen survival rates. A more feasible hypothesis is that the Amoy Gardens intra-building spread was through re-aerosolisation of contaminated waste water coming from the faulty plumbing system. Similar outbreaks have more recently been found<ref>Bhowmick, G.D., Dhar, D., Nath, D. et al. Coronavirus disease 2019 (COVID-19) outbreak: some serious consequences with urban and rural water cycle. npj Clean Water 3, 32 (2020). https://doi.org/10.1038/s41545-020-0079-1</ref>

==Institutional Guidance==
===WHO===
The WHO's advice regarding SARS-CoV-2 transmission during clinical interventions is as follows:
''"In the context of COVID-19, airborne transmission may be possible in specific circumstances and settings in which procedures or support treatments that generate aerosols are performed; i.e., endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, turning the patient to the prone position, disconnecting the patient from the ventilator, non-invasive positive-pressure ventilation, tracheostomy, and cardiopulmonary resuscitation."'' - WHO 2020<ref name="WHO 2020" /> 

While the WHO's position acknowledges the increased risk of transmission in overcrowded and under-ventilated spaces, the appropriate response is not to increase prescribed general ventilation rates, but rather to avoid overcrowding and maintain ventilation systems correctly.
===US-CDC===
The CDC's advice regarding SARS-CoV-2 transmission is still nearly identical to its guidance for SARS-CoV-1:
''"The primary transmission of COVID-19 is from person-to-person through respiratory droplets. These droplets are released when someone with COVID-19 sneezes or coughs. COVID-19 can also be spread when you are in close contact with someone who is sick (e.g., shaking hands or talking). A physical distance of at least 1 meter (3ft) between persons is suggested by the World Health Organization (WHO) to avoid infection, although some WHO member states have recommended maintaining greater distances whenever possible. Respiratory droplets can land on objects or surfaces around the person when they cough or talk, and people can then become infected with COVID-19 from touching these objects or surfaces and then touching their eyes, nose or mouth. Recent data suggests that there can be transmission of COVID-19 through droplets of those with mild symptoms or those who do not feel ill"'' <ref>https://www.cdc.gov/sars/about/faq.html</ref><ref>https://www.cdc.gov/sars/about/faq.html</ref>

The US-CDC's recommendations regarding inpatient accommodation for SARS includes the comment,
"Experience in some settings in Taiwan and Toronto demonstrated that cohorting SARS patients, without use of AIIRs, effectively interrupted transmission"<ref>US-CDC,2005, https://www.cdc.gov/sars/guidance/i-infection/healthcare.html</ref>
The CDC's guidance is consistent with the full context of hierarchical risk-based infection control and is suitably cognizant of variously resourced settings.
"Airborne Infection Isolation Rooms (AIIRs) (See definition of AIIR in appendix) should be reserved for patients who will be undergoing aerosol generating procedures (See Aerosol Generating Procedures Section)."<ref>Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (updated July 9, 2020)[https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html]</ref>
This nuanced approach is difficult to tease out of the guidance from engineering societies.

===ASHRAE===
While the US-CDC and WHO maintains that the airborne transmission is possible but not common or of primary concern, ASHRAE (being an association dedicated to ventilation engineering) focuses on the airborne component.
"Transmission of SARS-CoV-2 through the air is sufficiently likely that airborne exposure to the virus should be controlled. Changes to building operations, including the operation of heating, ventilating, and air-conditioning systems, can reduce airborne exposures"<ref>Q: Does ASHRAE’s guidance agree with guidance from WHO and CDC?[https://www.ashrae.org/file%20library/technical%20resources/covid-19/does-ashrae-s-guidance-agree-with-guidance-from-who-and-cdc.pdf]</ref>
ASHRAE makes useful distinctions between guidance for healthcare<ref>ASHRAE healthcare C19 guidance (ASHRAE 2020) [https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-healthcare-c19-guidance.pdf]</ref>, residential <ref>ASHRAE residential c19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-residential-c19-guidance.pdf]</ref><ref>COVID 19 guidance for multifamily building owners-managers (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/covid-19-guidance-for-multifamily-building-owners_managers.pdf]</ref>, commercial <ref>ASHRAE commercial C19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-commercial-c19-guidance.pdf]</ref> and schools<ref>ASHRAE Schools C19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-schools-c19-guidance.pdf</ref>, but doesn't significantly address risk categories specifically in healthcare or resource limited settings.
===REHVA===
REHVA's temporary guidance is limited to commercial and public buildings<ref>REHVA COVID-19 guidance document, April 3, 2020[https://www.rehva.eu/fileadmin/user_upload/REHVA_COVID-19_guidance_document_ver2_20200403_1.pdf]</ref>. Similar to ASHRAE, REHVA focusses on engineering controls for airborne transmission. REHVA acknowledges importance of droplet precautions and the lack of quality evidence for airborne transmission, but draws the conclusion that SARS-CoV-2 RNA found in ventilation ducting implies airborne transmission, even though these real world studies have not yet proven viability of these particles. REHVA also draws the airborne conclusion from the van Doremalen study<ref name="van Doremalen" /> out of its intended comparative context.

===IUSS (2014)===
The IUSS Building Engineering Services Guidelines<ref>Building Engineering Services (2014)[https://iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-services]</ref>, which is mandated for new buildings by provincial departments of health by reference in Government Notice R116<ref>Government Notice R116 (17 Feb 2014)[https://iussonline.co.za/docman/gazettes/116-notice-37348/file]</ref>, describes risk based ventilation criteria which are broadly appropriate for COVID-19, if not excessive. This guideline was developed with control measures for the current TB epidemic in mind. These measures would be more than appropriate for most healthcare spaces. The guidance recommends no recirculation of air between theatres and adjacent spaces but does not prohibit cascading from surgeries to adjacent spaces. Therefore, confirmed COVID-19 patients should only be treated in negative pressure operating rooms that comply with the guidelines.

==Engineering Response==

Ventilation society guidance understandably bears the risk of being biased toward over-prescribing solutions over which engineers have the greatest understanding and control. It is within this context that the valuable guidance published online by REHVA and ASHRAE should be considered. Revamping existing ventilation systems in resource-constrained healthcare settings to meet admittedly overly-cautious guidance should not be conducted without an informed investment case.
"In these resource limited settings, it needs to be carefully considered whether resources are allocated to clinical capacity or to possibly unnecessary ventilation when the benefits of these criteria may be comparatively marginal."

Without good viability studies of the viral particles found in ventilation systems, no firm guidance can be offered regarding the rate of reduction for SARS-CoV-2 viability with time and distance. Until that time it would be prudent to assume that the virus should only be considered as airborne under special and rare conditions, based on the guidance of the WHO. This would determine that we have different filtration and ventilation approaches between COVID-ICUs, general indoor public spaces and spaces with a potential for high density occupation.

For high-risk spaces it may be prudent to implement temporary measures to limit transmission risk to the minimum possible. In order of priorities, engineering interventions include:

#decongest indoor spaces to the minimum possible occupancy levels
#open windows to outside when occupational health, safety and security are not compromised
#increase HVAC fresh air rates to maximum possible levels
#reduce HVAC recirculation levels to minimum possible levels
#flush buildings with fresh air before and after daily occupancy

The following matrix is intended to guide our design responses for a sample of space types
{| class="wikitable"
|+Risk Response Matrix
!Space Type
!Risk
!Initial Risk
!Engineering Response
!Residual Risk
|-
| rowspan="2" |ICU
|Transmission in ICU
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Low
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Where high risks are associated with adjacent spaces, ventilate ICU in accordance with IUSS Guidelines for Airborne Precaution Rooms
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |Surgeries
|Transmission in Theatre
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs,
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Moderate
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Surgeries on identified COVID-19 patients in negative pressure theatres only.
##No recirculation to adjacent spaces (for negative pressure theatres)
##Ensure compliance with contact, droplet and airborne precautions for staff
##Where high risks are associated with adjacent spaces, ventilate the operating room in accordance with IUSS Guidelines for Airborne Precaution Rooms or sepsis theatres
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |COVID Wards
|Transmission within COVID-19 Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for general wards
#Keep available windows open when safe and secure
#Ensure compliance with contact, droplet and airborne precautions
|Low
|-
|Transmission to Adjacent spaces
|High
| 

#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
##Increase ventilation rates in adjacent areas (passages)
##Positive pressure relative to COVID wards
##Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
##Extraction systems to discharge safely at high-level
|Low
|-
|General wards
|Transmission within and from Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for General Wards
|Low
|-
|Emergency centre
|Transmission within EC
|High
|
#Reduce number of occupants to only essential staff and caregivers
#Screen and fast-track patients with respiratory illness symptoms
#Isolate persons under investigation for COVID-19
##Isolation rooms ventilated in accordance with IUSS guidance for airborne precaution rooms
|Moderate
|-
|Hospital Waiting Areas
|Transmission within waiting room
|High
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with IUSS Guidelines for Waiting Areas
|Moderate
|-
|Other public waiting spaces
|Transmission within waiting room
|Moderate
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with Building Regulations
|Moderate
|}
Therefore, assuming systems have been designed in accordance with the IUSS guidance, there should be little reason to change their configuration or pressurization unless general areas are repurposed as airborne precaution rooms. Risk assessments should be conducted for ICUs and COVID-19 wards immediately adjacent to public waiting areas or other high traffic areas, with corrective actions including but not limited to reducing occupancy times and rates for these areas.

 
----

==Notes and References==
[[Category:Reference Desk]]
[[Category:COVID-19]]
[[Category:ICU]]
[[Category:Airbone Infection control]]
<references />
[[Category:ASHRAE]]
[[Category:REHVA]]
[[Category:IUSS]]

Ventilation and COVID-19

2020-07-14T16:06:09Z

Peta: /* Transmission routes */

[[Category:COVID-19]]
[[Category:Airborne Contamination Control]]
[[Category:Crosscutting Issues]]

==Context==
This article aims to to contextualize COVID-19 related ventilation guidelines in a field of developing clinical evidence. This is done with the hope of empowering the reader to scrutinize proposed interventions within this context and employ appropriate and efficient solutions. The information and guidance in this article is the developing opinion of the author and does not represent any regulatory or institutional mandate or authority. The evidence supporting this opinion is evolving and therefore the opinion is similarly subject to change. The reader is encouraged to return to this article frequently to review any changes additions or updates highlighted in the history tab above.

Discussion and contributions are similarly welcomed in the discussion tab above.

==Background==

===Transmission routes===
SARS-CoV-2 seems to have caused many to rethink their understanding of droplet and airborne transmission. These two transmission mechanisms form a continuum, but the following is generally accepted:

*''Infectious'' particles <5μm in size can remain suspended and viable for many hours and these contribute to the risk of '''airborne transmission'''.
*'''Droplet transmission''' involves larger particles which can also spread through the air for some distance, but the range of transmission is generally considered to be less than 2 meters where after particles fall out of the breathing zone. It is important to remember that within this 2 m distance these larger droplets are essentially 'airborne' and diluting ventilation systems have little effect on reducing the risk of near-range droplet transmission<ref>Liu, L., Li, Y., Nielsen, P. V., Wei, J. & Jensen, R. L. Short-range airborne transmission of expiratory droplets between two people. Indoor Air 1–11 (2016) doi:10.1111/ina.12314.</ref>.

Droplet precautions, therefore, include standard precautions like PPE, hand washing and distancing, while airborne precautions include negative pressure isolation, respiratory protection, special exhaust or filtration regimes, etc.

Diseases seldom obey only one mode of transmission (obligatory transmission) but often have preferences (preferential transmission) while occasionally exploiting circumstances which provide rare opportunities for transmission (opportunistic routes). SARS-COV-2 is understood to be '''preferentially droplet and contact spread''' (a form of droplet spread where droplets can settle on fomites) with possible rare and opportunistic airborne spread, although an extensive outbreak review revealed no indication of airborne spread<ref>https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>.

===Airborne Transmission===
There is still little strong evidence of common long-range airborne transmission in the sense of droplet nucleation, as with TB and measles<ref>World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) 16-24 February 2020 [Internet]. Geneva: World Health Organization; 2020 Available from: [https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf]</ref>. Where evidence of airborne transmission has been reported, this can be seen in the context of opportunistic long-range droplet spread<ref> Wenzhao Chen, Nan Zhang, Jianjian Wei, Hui-LingYen, and Yuguo Li, “Short-range airborne route dominates exposure of respiratory infection during close contact,” medRxiv preprint, https://doi.org/10.1101/2020.03.16.20037291</ref>. A discussion contextualizing the reported cases of airborne transmission is discussed below. 

The van Doremalen SARS-CoV-2 survival study<ref name="van Doremalen">Neeltje van Doremalen, Trenton Bushmaker, Dylan H. Morris, Myndi G. Holbrook, Amandine Gamble, Brandi N. Williamson, Azaibi Tamin, Jennifer L. Harcourt, Natalie J. Thornburg, Susan I. Gerber, James O. LloydSmith, Emmie de Wit, and Vincent J. Munster, “Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1,” The New England Journal of Medicine (2020), DOI: 10.1056/NEJMc2004973 [https://www.nejm.org/doi/pdf/10.1056/NEJMc2004973?articleTools=true]</ref> is often incorrectly reported to have shown that SARS-CoV-2 can remain viable in air for extended periods. No evidence for long range airborne viability has yet been found outside of lab settings. SARS-CoV-2 virus found dispersed at long range has not been cultured to prove viability and many studies have failed to detect it directly in air in quantities substantial enough to culture<ref>Faridi, S. et al. A field indoor air measurement of SARS-CoV-2 in the patient rooms of the largest hospital in Iran. Sci. Total Environ. 725, 1–5 (2020).</ref><ref>Liu, Y. et al. Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals. Nature (2020) doi:10.1038/s41586-020-2271-3.</ref>. Correlations between culture viability, particle size and the real world infectious quantum were not described in this study<ref name="van Doremalen" /> as it was not the study's intention to claim COVID-19 was airborne. A more recent pre-publication article has made similar findings<ref>Fears SC, Klimstra WB, Duprex P, Hartman A, Weaver SC, Plante KS, et al. Persistence of severe acute respiratory syndrome coronavirus 2 in aerosol suspensions. Emerg Infect Dis. 2020 Sep [''date cited'']. <nowiki>https://doi.org/10.3201/eid2609.201806</nowiki></ref> but this has significant problems with equipment standardization and repeatability. More importantly, similar lab studies have also demonstrated a 3h airborne survival for viral strains such as Ebola not considered to be airborne<ref>Robert Comparison of the Aerosol Stability of 2 Strains of Zaire ebolavirus From the 1976 and 2013 Outbreaks Robert J. Fischer, Trenton Bushmaker, Seth Judson, Vincent J. Munster
J Infect Dis. 2016 Oct 15; 214(Suppl 3): S290–S293. Published online 2016 Oct 4. doi: 10.1093/infdis/jiw193 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5050463/</ref>. This makes the direct application of this lab study in real-world settings problematic.

Studies which have found real-world SARS-CoV-2 in air, ducting and on extraction fans have so far failed to prove that the virus found was still viable<ref>Santarpia et al, “Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center,. medRxiv preprint (2020), [https://doi.org/10.1101/2020.03.23.20039446]</ref><ref>Po Ying Chia et al, 2020 (Preprint) “Detection of Air and Surface Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in Hospital Rooms of Infective Patients,” medRxiv preprint (2020), https://doi.org/10.1101/2020.03.29.20046557 [https://www.medrxiv.org/content/10.1101/2020.03.29.20046557v2.full.pdf]</ref>.

Therefore, the understanding of the mechanisms of COVID-19 transmission is still largely reliant on what is understood of SARS (SARS-CoV-1)<ref>Isao Arita, Kazunobu Kojima, and Miyuki Nakane, “Transmission of severe acute respiratory syndrome,” Emerging. Infectious Diseases 9 No. 9 (2003):1183-84, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016764/].</ref>

 It has been suggested that high temperature and humidity would reduce the spread of the virus<ref>Chin, A. W. H. et al. Stability of SARS-CoV-2 in different environmental conditions. The Lancet Microbe 0–4 (2020) doi:10.1016/s2666-5247(20)30003-3.</ref><ref>Pyankov, O. V., Bodnev, S. A., Pyankova, O. G. & Agranovski, I. E. Survival of aerosolized coronavirus in the ambient air. J. Aerosol Sci. 115, (2018).</ref>. The temperature ranges suggested (>50°C) are beyond what anyone could endure in an ICU but the humidity ranges of between 40-60% are achievable. The high humidity slows the nucleation of the viral droplet and increases its settling speed, thereby reducing its range.
====High Risk Settings (ICU)====
Much of the work being done to understand the transmission mechanism of COVID-19 is focused on community transmission. It is important to remember that transmission risk in an ICU will not be the same as in homes and workplaces. The conditions and procedures in ICUs could promote transmission - see WHO 2020 below<ref name="WHO 2020">WHO 2020, Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>. Firstly, in a COVID ICU unit, the contamination source strength is much higher than other spaces since infected patients are congregated there. These are presumably ill patients with high viral shedding. Secondly, procedures like intubation are understood to release high quantities of aerosolized particles, unlike with general talking or coughing. Additionally, viral shedding through talking and coughing can be more readily mitigated than from intubation.

===Fecal-Oral Transmission===
Fecal oral route of transmission is acknowledged for COVID-19<ref>Pan Y, Zhang D, Yang P, Poon LLM, Wang Q. Viral load of SARS-CoV-2 in clinical samples. Lancet Infect Dis. 2020;20(4):411-2.</ref> and considerations for waste water management are discussed [[SARS-CoV-2 is found in faecal matter|here]] and [https://doi.org/10.1016/j.scitotenv.2020.139076 here]<ref>Kitajima et al,SARS-CoV-2 in wastewater: State of the knowledge and research needs,Science of The Total Environment,Volume 739,2020,139076,ISSN 0048-9697,<nowiki>https://doi.org/10.1016/j.scitotenv.2020.139076</nowiki></ref>

This transmission route indirectly affects ventilation system design as special consideration should be given to common scenarios where the aerosolisation of contaminated wastewater is a possibility such as in bathrooms, sluice rooms and slurry pumping. These spaces should be well-ventilated and kept under negative pressure relative to adjacent spaces.

====A Note on ''Amoy Gardens'' SARS studies<ref>McKinney KR, Gong YY, Lewis TG. Environmental transmission of SARS at Amoy Gardens. ''J Environ Health''. 2006;68(9):26-52.</ref>====
Studies, which indicate the Amoy Gardens building's SARS outbreaks' transmission was via the airborne route, commonly reference the prevailing wind between buildings. It should be noted that, since these buildings are about 60m apart the environmental dilution and concentration decay effects are so strong it is not feasible that an infectious dose persists at that range. Similarly, the possibility that air can commute out of one window and into another needs to account for these dilution effects before assumptions of transmission can be drawn. These studies do not sufficiently account for dilution, infectious doses and pathogen survival rates. A more feasible hypothesis is that the Amoy Gardens intra-building spread was through re-aerosolisation of contaminated waste water coming from the faulty plumbing system. Similar outbreaks have more recently been found <ref>Bhowmick, G.D., Dhar, D., Nath, D. et al. Coronavirus disease 2019 (COVID-19) outbreak: some serious consequences with urban and rural water cycle. npj Clean Water 3, 32 (2020). https://doi.org/10.1038/s41545-020-0079-1</ref>

==Institutional Guidance==
===WHO===
The WHO's advice regarding SARS-CoV-2 transmission during clinical interventions is as follows:
''"In the context of COVID-19, airborne transmission may be possible in specific circumstances and settings in which procedures or support treatments that generate aerosols are performed; i.e., endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, turning the patient to the prone position, disconnecting the patient from the ventilator, non-invasive positive-pressure ventilation, tracheostomy, and cardiopulmonary resuscitation."'' - WHO 2020<ref name="WHO 2020" /> 

While the WHO's position acknowledges the increased risk of transmission in overcrowded and under-ventilated spaces, the appropriate response is not to increase prescribed general ventilation rates, but rather to avoid overcrowding and maintain ventilation systems correctly.
===US-CDC===
The CDC's advice regarding SARS-CoV-2 transmission is still nearly identical to its guidance for SARS-CoV-1:
''"The primary transmission of COVID-19 is from person-to-person through respiratory droplets. These droplets are released when someone with COVID-19 sneezes or coughs. COVID-19 can also be spread when you are in close contact with someone who is sick (e.g., shaking hands or talking). A physical distance of at least 1 meter (3ft) between persons is suggested by the World Health Organization (WHO) to avoid infection, although some WHO member states have recommended maintaining greater distances whenever possible. Respiratory droplets can land on objects or surfaces around the person when they cough or talk, and people can then become infected with COVID-19 from touching these objects or surfaces and then touching their eyes, nose or mouth. Recent data suggests that there can be transmission of COVID-19 through droplets of those with mild symptoms or those who do not feel ill"'' <ref>https://www.cdc.gov/sars/about/faq.html</ref><ref>https://www.cdc.gov/sars/about/faq.html</ref>

The US-CDC's recommendations regarding inpatient accommodation for SARS includes the comment,
"Experience in some settings in Taiwan and Toronto demonstrated that cohorting SARS patients, without use of AIIRs, effectively interrupted transmission"<ref>US-CDC,2005, https://www.cdc.gov/sars/guidance/i-infection/healthcare.html</ref>
The CDC's guidance is consistent with the full context of hierarchical risk-based infection control and is suitably cognizant of variously resourced settings.
"Airborne Infection Isolation Rooms (AIIRs) (See definition of AIIR in appendix) should be reserved for patients who will be undergoing aerosol generating procedures (See Aerosol Generating Procedures Section)."<ref>Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (updated July 9, 2020)[https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html]</ref>
This nuanced approach is difficult to tease out of the guidance from engineering societies.

===ASHRAE===
While the US-CDC and WHO maintains that the airborne transmission is possible but not common or of primary concern, ASHRAE (being an association dedicated to ventilation engineering) focuses on the airborne component.
"Transmission of SARS-CoV-2 through the air is sufficiently likely that airborne exposure to the virus should be controlled. Changes to building operations, including the operation of heating, ventilating, and air-conditioning systems, can reduce airborne exposures"<ref>Q: Does ASHRAE’s guidance agree with guidance from WHO and CDC?[https://www.ashrae.org/file%20library/technical%20resources/covid-19/does-ashrae-s-guidance-agree-with-guidance-from-who-and-cdc.pdf]</ref>
ASHRAE makes useful distinctions between guidance for healthcare<ref>ASHRAE healthcare C19 guidance (ASHRAE 2020) [https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-healthcare-c19-guidance.pdf]</ref>, residential <ref>ASHRAE residential c19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-residential-c19-guidance.pdf]</ref><ref>COVID 19 guidance for multifamily building owners-managers (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/covid-19-guidance-for-multifamily-building-owners_managers.pdf]</ref>, commercial <ref>ASHRAE commercial C19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-commercial-c19-guidance.pdf]</ref> and schools<ref>ASHRAE Schools C19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-schools-c19-guidance.pdf</ref>, but doesn't significantly address risk categories specifically in healthcare or resource limited settings.
===REHVA===
REHVA's temporary guidance is limited to commercial and public buildings<ref>REHVA COVID-19 guidance document, April 3, 2020[https://www.rehva.eu/fileadmin/user_upload/REHVA_COVID-19_guidance_document_ver2_20200403_1.pdf]</ref>
Similarly to ASHRAE, REHVA focusses on engineering controls for airborne transmission. REHVA acknowledges importance of droplet precautions and the lack of quality evidence for airborne transmission, but draws the conclusion that SARS-CoV-2 RNA found in ventilation ducting implies airborne transmission, even though these real world studies have not yet proven viability of these particles. REHVA also draws the airborne conclusion from the van Doremalen study <ref name="van Doremalen" />out of its intended comparative context.

===IUSS (2014)===
The IUSS Building Engineering Services Guidelines <ref>Building Engineering Services (2014)[https://iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-services]</ref>, which is mandated for new buildings by provincial departments of health by reference in Government Notice R116<ref>Government Notice R116 (17 Feb 2014)[https://iussonline.co.za/docman/gazettes/116-notice-37348/file]</ref>, describes risk based ventilation criteria which are broadly appropriate for COVID-19, if not excessive. This guideline was developed with control measures for the current TB epidemic in mind. These measures would be more than appropriate for most healthcare spaces. The guidance recommends no recirculation of air between theatres and adjacent spaces but does not prohibit cascading from surgeries to adjacent spaces. Therefore, confirmed COVID-19 patients should only be treated in negative pressure operating rooms that comply with the guidelines.

==Engineering Repsonse==

Ventilation society guidance understandably bears the risk of being biased toward over-prescribing solutions over which engineers have the greatest understanding and control. It is within this context that the valuable guidance published online by REHVA and ASHRAE should be considered. Revamping existing ventilation systems in resource-constrained healthcare settings to meet admittedly overly-cautious guidance should not be conducted without an informed investment case.
"In these resource limited settings, it needs to be carefully considered whether resources are allocated to clinical capacity or to possibly unnecessary ventilation when the benefits of these criteria may be comparatively marginal."

Without good viability studies of the viral particles found in ventilation systems, no firm guidance can be offered regarding the rate of reduction for SARS-CoV-2 viability with time and distance. Until that time it would be prudent to assume that the virus should only be considered as airborne under special and rare conditions, based on the guidance of the WHO. This would determine that we have different filtration and ventilation approaches between COVID-ICUs, general indoor public spaces and spaces with a potential for high density occupation.

For high-risk spaces it may be prudent to implement temporary measures to limit transmission risk to the minimum possible. In order of priorities, engineering interventions include:

#decongest indoor spaces to the minimum possible occupancy levels
#open windows to outside when occupational health, safety and security are not compromised
#increase HVAC fresh air rates to maximum possible levels
#reduce HVAC recirculation levels to minimum possible levels
#flush buildings with fresh air before and after daily occupancy

The following matrix is intended to guide our design responses for a sample of space types
{| class="wikitable"
|+Risk Response Matrix
!Space Type
!Risk
!Initial Risk
!Engineering Response
!Residual Risk
|-
| rowspan="2" |ICU
|Transmission in ICU
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Low
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Where high risks are associated with adjacent spaces, ventilate ICU in accordance with IUSS Guidelines for Airborne Precaution Rooms
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |Surgeries
|Transmission in Theatre
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs,
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Moderate
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Surgeries on identified COVID-19 patients in negative pressure theatres only.
##No recirculation to adjacent spaces (for negative pressure theatres)
##Ensure compliance with contact, droplet and airborne precautions for staff
##Where high risks are associated with adjacent spaces, ventilate the operating room in accordance with IUSS Guidelines for Airborne Precaution Rooms or sepsis theatres
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |COVID Wards
|Transmission within COVID-19 Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for general wards
#Keep available windows open when safe and secure
#Ensure compliance with contact, droplet and airborne precautions
|Low
|-
|Transmission to Adjacent spaces
|High
| 

#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
##Increase ventilation rates in adjacent areas (passages)
##Positive pressure relative to COVID wards
##Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
##Extraction systems to discharge safely at high-level
|Low
|-
|General wards
|Transmission within and from Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for General Wards
|Low
|-
|Emergency centre
|Transmission within EC
|High
|
#Reduce number of occupants to only essential staff and caregivers
#Screen and fast-track patients with respiratory illness symptoms
#Isolate persons under investigation for COVID-19
##Isolation rooms ventilated in accordance with IUSS guidance for airborne precaution rooms
|Moderate
|-
|Hospital Waiting Areas
|Transmission within waiting room
|High
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with IUSS Guidelines for Waiting Areas
|Moderate
|-
|Other public waiting spaces
|Transmission within waiting room
|Moderate
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with Building Regulations
|Moderate
|}
Therefore, assuming systems have been designed in accordance with the IUSS guidance, there should be little reason to change their configuration or pressurization unless general areas are repurposed as airborne precaution rooms. Risk assessments should be conducted for ICUs and COVID-19 wards immediately adjacent to public waiting areas or other high traffic areas, with corrective actions including but not limited to reducing occupancy times and rates for these areas.

 
----

==Notes and References==
[[Category:Reference Desk]]
[[Category:COVID-19]]
[[Category:ICU]]
[[Category:Airbone Infection control]]
<references />
[[Category:ASHRAE]]
[[Category:REHVA]]
[[Category:IUSS]]

Ventilation and COVID-19

2020-07-13T17:35:48Z

Peta: /* High Risk Settings */

'''THIS ARTICLE IS STILL BEING ACTIVELY WRITTEN AND EDITED. PLEASE RETURN FOR THE COMPLETED WORK SHORTLY.'''
{{Expand}}
[[Category:COVID-19]]
[[Category:Airborne Contamination Control]]
[[Category:Crosscutting Issues]]

==Background==

===Transmission routes===
SARS-CoV-2 seems to have caused many to rethink their understanding of droplet and airborne transmission. These two transmission mechanisms form a continuum, but the following is generally accepted:

*''Infectious'' particles <5μm in size can remain suspended and viable for many hours and these contribute to the risk of '''airborne transmission'''.
*'''Droplet transmission''' involves larger particles which can also spread through the air for some distance, but the range of transmission is generally considered to be less than 2 meters where after particles fall out of the breathing zone. It is important to remember that within this 2 m distance these larger droplets are essentially 'airborne' and diluting ventilation systems have little effect on reducing the risk of near-range droplet transmission<ref>Liu, L., Li, Y., Nielsen, P. V., Wei, J. & Jensen, R. L. Short-range airborne transmission of expiratory droplets between two people. Indoor Air 1–11 (2016) doi:10.1111/ina.12314.</ref>.

Droplet precautions, therefore, include standard precautions like PPE, hand washing and distancing while airborne precautions include negative pressure isolation, respiratory protection, special exhaust or filtration regimes, etc.

Diseases seldom obey only one mode of transmission (obligatory transmission) but often have preferences (preferential transmission) while occasionally exploiting circumstances which provide rare opportunities for transmission (opportunistic routes). SARS-COV-2 is understood to be '''preferentially droplet and contact spread''' (a form of droplet spread where droplets can settle on fomites) with possible rare and opportunistic airborne spread, although an extensive outbreak review revealed no indication of airborne spread<ref>https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>.

===Airborne Transmission===
There is still little strong evidence of common long-range airborne transmission in the sense of droplet nucleation, as with TB and measles<ref>World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) 16-24 February 2020 [Internet]. Geneva: World Health Organization; 2020 Available from: [https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf]</ref>. Where evidence of airborne transmission has been reported, this can be seen in the context of opportunistic long-range droplet spread<ref> Wenzhao Chen, Nan Zhang, Jianjian Wei, Hui-LingYen, and Yuguo Li, “Short-range airborne route dominates exposure of respiratory infection during close contact,” medRxiv preprint, https://doi.org/10.1101/2020.03.16.20037291</ref>. A discussion contextualizing the reported cases of airborne transmission is discussed below. 

Van Doremalen's SARS-CoV-2 survival study is often incorrectly reported to have shown that SARS-CoV-2 can remain viable in air for extended periods<ref name="van Doremalen">Neeltje van Doremalen, Trenton Bushmaker, Dylan H. Morris, Myndi G. Holbrook, Amandine Gamble, Brandi N. Williamson, Azaibi Tamin, Jennifer L. Harcourt, Natalie J. Thornburg, Susan I. Gerber, James O. LloydSmith, Emmie de Wit, and Vincent J. Munster, “Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1,” The New England Journal of Medicine (2020), DOI: 10.1056/NEJMc2004973 [https://www.nejm.org/doi/pdf/10.1056/NEJMc2004973?articleTools=true]</ref>. No evidence for airborne viability has yet been found outside of lab settings. SARS-CoV-2 virus found dispersed at long range has not been cultured to prove viability and many studies have failed to detect it directly in air in quantities substantial enough to culture<ref>Faridi, S. et al. A field indoor air measurement of SARS-CoV-2 in the patient rooms of the largest hospital in Iran. Sci. Total Environ. 725, 1–5 (2020).</ref><ref>Liu, Y. et al. Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals. Nature (2020) doi:10.1038/s41586-020-2271-3.</ref>. Correlations between culture viability, particle size and the real world infectious quantum were not described in this study<ref name="van Doremalen" /> and it was not the study's intention to claim COVID-19 was airborne. More recent studies have made similar findings<ref>Fears SC, Klimstra WB, Duprex P, Hartman A, Weaver SC, Plante KS, et al. Persistence of severe acute respiratory syndrome coronavirus 2 in aerosol suspensions. Emerg Infect Dis. 2020 Sep [''date cited'']. <nowiki>https://doi.org/10.3201/eid2609.201806</nowiki></ref>. More importantly, similar lab studies have also demonstrated a 3h airborne survival for viral strains not thought to be airborne<ref>Robert Comparison of the Aerosol Stability of 2 Strains of Zaire ebolavirus From the 1976 and 2013 Outbreaks Robert J. Fischer, Trenton Bushmaker, Seth Judson, Vincent J. Munster
J Infect Dis. 2016 Oct 15; 214(Suppl 3): S290–S293. Published online 2016 Oct 4. doi: 10.1093/infdis/jiw193 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5050463/</ref>. This makes the direct application of this lab study in real-world settings problematic. 

Therefore, the understanding of the mechanisms of COVID-19 transmission is still largely reliant on what is understood of SARS (SARS-CoV-1)<ref>Isao Arita, Kazunobu Kojima, and Miyuki Nakane, “Transmission of severe acute respiratory syndrome,” Emerging. Infectious Diseases 9 No. 9 (2003):1183-84, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016764/].</ref> The CDC's advice regarding SARS-CoV-2 transmission is still nearly identical to it's guidance for SARS-CoV-1:
''"The primary transmission of COVID-19 is from person-to-person through respiratory droplets. These droplets are released when someone with COVID-19 sneezes or coughs. COVID-19 can also be spread when you are in close contact with someone who is sick (e.g., shaking hands or talking). A physical distance of at least 1 meter (3ft) between persons is suggested by the World Health Organization (WHO) to avoid infection, although some WHO member states have recommended maintaining greater distances whenever possible. Respiratory droplets can land on objects or surfaces around the person when they cough or talk, and people can then become infected with COVID-19 from touching these objects or surfaces and then touching their eyes, nose or mouth. Recent data suggests that there can be transmission of COVID-19 through droplets of those with mild symptoms or those who do not feel ill"'' <ref>https://www.cdc.gov/sars/about/faq.html</ref><ref>https://www.cdc.gov/sars/about/faq.html</ref>

Studies which have found real-world SARS-CoV-2 in air, ducting and on extraction fans have so far failed to prove that the virus found was still viable<ref>Santarpia et al, “Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center,. medRxiv preprint (2020), [https://doi.org/10.1101/2020.03.23.20039446]</ref><ref>Po Ying Chia et al, 2020 (Preprint) “Detection of Air and Surface Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in Hospital Rooms of Infective Patients,” medRxiv preprint (2020), https://doi.org/10.1101/2020.03.29.20046557 [https://www.medrxiv.org/content/10.1101/2020.03.29.20046557v2.full.pdf]</ref>. It has been suggested that high temperature and humidity would reduce the spread of the virus<ref>Chin, A. W. H. et al. Stability of SARS-CoV-2 in different environmental conditions. The Lancet Microbe 0–4 (2020) doi:10.1016/s2666-5247(20)30003-3.</ref><ref>Pyankov, O. V., Bodnev, S. A., Pyankova, O. G. & Agranovski, I. E. Survival of aerosolized coronavirus in the ambient air. J. Aerosol Sci. 115, (2018).</ref>. The temperature ranges suggested (>50°C) are beyond what anyone could endure in an ICU but the humidity ranges of between 40-60% are achievable. The high humidity slows the nucleation of the viral droplet and increases its settling speed, thereby reducing its range.

====High Risk Settings====
Much of the work being done to understand the transmission mechanism of COVID-19 is focused on community transmission. It is important to remember that transmission risk in an ICU will not be the same as in homes and workplaces. The conditions and procedures in ICUs could promote transmission - see WHO 2020 below<ref name="WHO 2020">WHO 2020, Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>. Firstly, in a COVID ICU unit, the contamination source strength is much higher than other spaces since infected patients are congregated there. These are presumably ill patients with high viral shedding. Secondly, procedures like intubation are understood to release high quantities of aerosolized particles, unlike with general talking or coughing. Additionally, viral shedding through talking and coughing can be more readily mitigated than from intubation.

===Fecal-Oral Transmission===
Fecal oral route of transmission is acknowledged for COVID-19<ref>Pan Y, Zhang D, Yang P, Poon LLM, Wang Q. Viral load of SARS-CoV-2 in clinical samples. Lancet Infect Dis. 2020;20(4):411-2.</ref> and considerations for waste water management are discussed [[SARS-CoV-2 is found in faecal matter|here]].

This transmission route indirectly affects ventilation system design as special consideration should be given to common scenarios where the aerosolisation of contaminated wastewater is a possibility such as in bathrooms, sluice rooms and slurry pumping. These spaces should be well-ventilated and kept under negative pressure relative to adjacent spaces.

====A Note on ''Amoy Gardens'' SARS studies<ref>McKinney KR, Gong YY, Lewis TG. Environmental transmission of SARS at Amoy Gardens. ''J Environ Health''. 2006;68(9):26-52.</ref>====
Studies, which indicate the Amoy Gardens building's SARS outbreaks' transmission was via the airborne route, commonly reference the prevailing wind between buildings. It should be noted that, since these buildings are about 60m apart the environmental dilution and concentration decay effects are so strong it is not feasible that an infectious dose persists at that range. Similarly, the possibility that air can commute out of one window and into another needs to account for these dilution effects before assumptions of transmission can be drawn. These studies do not sufficiently account for dilution, infectious doses and pathogen survival rates. A more feasible hypothesis is that the Amoy Gardens intra-building spread was through re-aerosolisation of contaminated waste water coming from the faulty plumbing system.

==Institutional Guidance==
The WHO's advice regarding SARS-CoV-2 transmission during clinical interventions is as follows:
''"In the context of COVID-19, airborne transmission may be possible in specific circumstances and settings in which procedures or support treatments that generate aerosols are performed; i.e., endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, turning the patient to the prone position, disconnecting the patient from the ventilator, non-invasive positive-pressure ventilation, tracheostomy, and cardiopulmonary resuscitation."'' - WHO 2020<ref name="WHO 2020" /> 

While the WHO's position acknowledges the increased risk of transmission in overcrowded and under-ventilated spaces, the appropriate response is not to increase prescribed general ventilation rates, but rather to avoid overcrowding and maintain ventilation systems correctly.

The US-CDC's recommendations regarding inpatient accommodation include the comment,
"Experience in some settings in Taiwan and Toronto demonstrated that cohorting SARS patients, without use of AIIRs, effectively interrupted transmission"<ref>US-CDC,2005, https://www.cdc.gov/sars/guidance/i-infection/healthcare.html</ref>

==Engineering Controls==

Without good viability studies of the viral particles found in ventilation systems, no firm guidance can be offered regarding the rate of reduction for SARS-CoV-2 viability with time and distance. Until that time it would be prudent to assume that the virus should only be considered as airborne under special and rare conditions, based on the guidance of the WHO. This would determine that we have different filtration and ventilation approaches between COVID-ICUs, general indoor public spaces and spaces with a potential for high density occupation.

For high-risk spaces it may be prudent to implement temporary measures to limit transmission risk to the minimum possible. In order of priorities, engineering interventions include:

#decongest indoor spaces to the minimum possible occupancy levels
#open windows to outside when occupational health, safety and security are not compromised
#increase HVAC fresh air rates to maximum possible levels
#reduce HVAC recirculation levels to minimum possible levels
#flush buildings with fresh air before and after daily occupancy

The following matrix is intended to guide our design responses for a sample of space types
{| class="wikitable"
|+Risk Response Matrix
!Space Type
!Risk
!Initial Risk
!Engineering Response
!Residual Risk
|-
| rowspan="2" |ICU
|Transmission in ICU
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Low
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Where high risks are associated with adjacent spaces, ventilate ICU in accordance with IUSS Guidelines for Airborne Precaution Rooms
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |Surgeries
|Transmission in Theatre
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs,
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Moderate
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Surgeries on identified COVID-19 patients in containment or sepsis theatres
##No recirculation to adjacent spaces
##Ensure compliance with contact, droplet and airborne precautions for staff
##Where high risks are associated with adjacent spaces, ventilate the operating room in accordance with IUSS Guidelines for Airborne Precaution Rooms or sepsis theatres
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |COVID Wards
|Transmission within COVID-19 Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for general wards
#Keep available windows open when safe and secure
#Ensure compliance with contact, droplet and airborne precautions
|Low
|-
|Transmission to Adjacent spaces
|High
| 

#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
##Increase ventilation rates in adjacent areas (passages)
##Positive pressure relative to COVID wards
##Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
##Extraction systems to discharge safely at high-level
|Low
|-
|General wards
|Transmission within and from Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for General Wards
|Low
|-
|Emergency centre
|Transmission within EC
|High
|
#Reduce number of occupants to only essential staff and caregivers
#Screen and fast-track patients with respiratory illness symptoms
#Isolate persons under investigation for COVID-19
##Isolation rooms ventilated in accordance with IUSS guidance for airborne precaution rooms
|Moderate
|-
|Hospital Waiting Areas
|Transmission within waiting room
|High
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with IUSS Guidelines for Waiting Areas
|Moderate
|-
|Other public waiting spaces
|Transmission within waiting room
|Moderate
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with Building Regulations
|Moderate
|}
Therefore, assuming systems have been designed in accordance with the IUSS guidance, there should be little reason to change their configuration or pressurization unless general areas are repurposed as airborne precaution rooms. Risk assessments should be conducted for ICUs and COVID-19 wards immediately adjacent to public waiting areas or other high traffic areas, with corrective actions including but not limited to reducing occupancy times and rates for these areas.

 
----

==Notes and References==
[[Category:Reference Desk]]
[[Category:COVID-19]]
[[Category:ICU]]
[[Category:Airbone Infection control]]
<references />

Ventilation and COVID-19

2020-07-13T17:33:57Z

Peta: /* A Note on Amoy Gardens SARS studies[19] */

'''THIS ARTICLE IS STILL BEING ACTIVELY WRITTEN AND EDITED. PLEASE RETURN FOR THE COMPLETED WORK SHORTLY.'''
{{Expand}}
[[Category:COVID-19]]
[[Category:Airborne Contamination Control]]
[[Category:Crosscutting Issues]]

==Background==

===Transmission routes===
SARS-CoV-2 seems to have caused many to rethink their understanding of droplet and airborne transmission. These two transmission mechanisms form a continuum, but the following is generally accepted:

*''Infectious'' particles <5μm in size can remain suspended and viable for many hours and these contribute to the risk of '''airborne transmission'''.
*'''Droplet transmission''' involves larger particles which can also spread through the air for some distance, but the range of transmission is generally considered to be less than 2 meters where after particles fall out of the breathing zone. It is important to remember that within this 2 m distance these larger droplets are essentially 'airborne' and diluting ventilation systems have little effect on reducing the risk of near-range droplet transmission<ref>Liu, L., Li, Y., Nielsen, P. V., Wei, J. & Jensen, R. L. Short-range airborne transmission of expiratory droplets between two people. Indoor Air 1–11 (2016) doi:10.1111/ina.12314.</ref>.

Droplet precautions, therefore, include standard precautions like PPE, hand washing and distancing while airborne precautions include negative pressure isolation, respiratory protection, special exhaust or filtration regimes, etc.

Diseases seldom obey only one mode of transmission (obligatory transmission) but often have preferences (preferential transmission) while occasionally exploiting circumstances which provide rare opportunities for transmission (opportunistic routes). SARS-COV-2 is understood to be '''preferentially droplet and contact spread''' (a form of droplet spread where droplets can settle on fomites) with possible rare and opportunistic airborne spread, although an extensive outbreak review revealed no indication of airborne spread<ref>https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>.

===Airborne Transmission===
There is still little strong evidence of common long-range airborne transmission in the sense of droplet nucleation, as with TB and measles<ref>World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) 16-24 February 2020 [Internet]. Geneva: World Health Organization; 2020 Available from: [https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf]</ref>. Where evidence of airborne transmission has been reported, this can be seen in the context of opportunistic long-range droplet spread<ref> Wenzhao Chen, Nan Zhang, Jianjian Wei, Hui-LingYen, and Yuguo Li, “Short-range airborne route dominates exposure of respiratory infection during close contact,” medRxiv preprint, https://doi.org/10.1101/2020.03.16.20037291</ref>. A discussion contextualizing the reported cases of airborne transmission is discussed below. 

Van Doremalen's SARS-CoV-2 survival study is often incorrectly reported to have shown that SARS-CoV-2 can remain viable in air for extended periods<ref name="van Doremalen">Neeltje van Doremalen, Trenton Bushmaker, Dylan H. Morris, Myndi G. Holbrook, Amandine Gamble, Brandi N. Williamson, Azaibi Tamin, Jennifer L. Harcourt, Natalie J. Thornburg, Susan I. Gerber, James O. LloydSmith, Emmie de Wit, and Vincent J. Munster, “Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1,” The New England Journal of Medicine (2020), DOI: 10.1056/NEJMc2004973 [https://www.nejm.org/doi/pdf/10.1056/NEJMc2004973?articleTools=true]</ref>. No evidence for airborne viability has yet been found outside of lab settings. SARS-CoV-2 virus found dispersed at long range has not been cultured to prove viability and many studies have failed to detect it directly in air in quantities substantial enough to culture<ref>Faridi, S. et al. A field indoor air measurement of SARS-CoV-2 in the patient rooms of the largest hospital in Iran. Sci. Total Environ. 725, 1–5 (2020).</ref><ref>Liu, Y. et al. Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals. Nature (2020) doi:10.1038/s41586-020-2271-3.</ref>. Correlations between culture viability, particle size and the real world infectious quantum were not described in this study<ref name="van Doremalen" /> and it was not the study's intention to claim COVID-19 was airborne. More recent studies have made similar findings<ref>Fears SC, Klimstra WB, Duprex P, Hartman A, Weaver SC, Plante KS, et al. Persistence of severe acute respiratory syndrome coronavirus 2 in aerosol suspensions. Emerg Infect Dis. 2020 Sep [''date cited'']. <nowiki>https://doi.org/10.3201/eid2609.201806</nowiki></ref>. More importantly, similar lab studies have also demonstrated a 3h airborne survival for viral strains not thought to be airborne<ref>Robert Comparison of the Aerosol Stability of 2 Strains of Zaire ebolavirus From the 1976 and 2013 Outbreaks Robert J. Fischer, Trenton Bushmaker, Seth Judson, Vincent J. Munster
J Infect Dis. 2016 Oct 15; 214(Suppl 3): S290–S293. Published online 2016 Oct 4. doi: 10.1093/infdis/jiw193 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5050463/</ref>. This makes the direct application of this lab study in real-world settings problematic. 

Therefore, the understanding of the mechanisms of COVID-19 transmission is still largely reliant on what is understood of SARS (SARS-CoV-1)<ref>Isao Arita, Kazunobu Kojima, and Miyuki Nakane, “Transmission of severe acute respiratory syndrome,” Emerging. Infectious Diseases 9 No. 9 (2003):1183-84, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016764/].</ref> The CDC's advice regarding SARS-CoV-2 transmission is still nearly identical to it's guidance for SARS-CoV-1:
''"The primary transmission of COVID-19 is from person-to-person through respiratory droplets. These droplets are released when someone with COVID-19 sneezes or coughs. COVID-19 can also be spread when you are in close contact with someone who is sick (e.g., shaking hands or talking). A physical distance of at least 1 meter (3ft) between persons is suggested by the World Health Organization (WHO) to avoid infection, although some WHO member states have recommended maintaining greater distances whenever possible. Respiratory droplets can land on objects or surfaces around the person when they cough or talk, and people can then become infected with COVID-19 from touching these objects or surfaces and then touching their eyes, nose or mouth. Recent data suggests that there can be transmission of COVID-19 through droplets of those with mild symptoms or those who do not feel ill"'' <ref>https://www.cdc.gov/sars/about/faq.html</ref><ref>https://www.cdc.gov/sars/about/faq.html</ref>

Studies which have found real-world SARS-CoV-2 in air, ducting and on extraction fans have so far failed to prove that the virus found was still viable<ref>Santarpia et al, “Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center,. medRxiv preprint (2020), [https://doi.org/10.1101/2020.03.23.20039446]</ref><ref>Po Ying Chia et al, 2020 (Preprint) “Detection of Air and Surface Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in Hospital Rooms of Infective Patients,” medRxiv preprint (2020), https://doi.org/10.1101/2020.03.29.20046557 [https://www.medrxiv.org/content/10.1101/2020.03.29.20046557v2.full.pdf]</ref>. It has been suggested that high temperature and humidity would reduce the spread of the virus<ref>Chin, A. W. H. et al. Stability of SARS-CoV-2 in different environmental conditions. The Lancet Microbe 0–4 (2020) doi:10.1016/s2666-5247(20)30003-3.</ref><ref>Pyankov, O. V., Bodnev, S. A., Pyankova, O. G. & Agranovski, I. E. Survival of aerosolized coronavirus in the ambient air. J. Aerosol Sci. 115, (2018).</ref>. The temperature ranges suggested (>50°C) are beyond what anyone could endure in an ICU but the humidity ranges of between 40-60% are achievable. The high humidity slows the nucleation of the viral droplet and increases its settling speed, thereby reducing its range.

====High Risk Settings====
Much of the work being done to understand the transmission mechanism of COVID-19 is focused on community transmission. It is important to remember that transmission risk in an ICU will not be the same as in homes and workplaces. The conditions and procedures in ICUs could promote transmission<see WHO 2020 below<ref name="WHO 2020">WHO 2020, Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>. Firstly, in a COVID ICU unit, the contamination source strength is much higher than other spaces since infected patients are congregated there. These are presumably ill patients with high viral shedding. Secondly, procedures like intubation are understood to release high quantities of aerosolized particles, unlike with general talking or coughing. Additionally, viral shedding through talking and coughing can be more readily mitigated than from intubation.

===Fecal-Oral Transmission===
Fecal oral route of transmission is acknowledged for COVID-19<ref>Pan Y, Zhang D, Yang P, Poon LLM, Wang Q. Viral load of SARS-CoV-2 in clinical samples. Lancet Infect Dis. 2020;20(4):411-2.</ref> and considerations for waste water management are discussed [[SARS-CoV-2 is found in faecal matter|here]].

This transmission route indirectly affects ventilation system design as special consideration should be given to common scenarios where the aerosolisation of contaminated wastewater is a possibility such as in bathrooms, sluice rooms and slurry pumping. These spaces should be well-ventilated and kept under negative pressure relative to adjacent spaces.

====A Note on ''Amoy Gardens'' SARS studies<ref>McKinney KR, Gong YY, Lewis TG. Environmental transmission of SARS at Amoy Gardens. ''J Environ Health''. 2006;68(9):26-52.</ref>====
Studies, which indicate the Amoy Gardens building's SARS outbreaks' transmission was via the airborne route, commonly reference the prevailing wind between buildings. It should be noted that, since these buildings are about 60m apart the environmental dilution and concentration decay effects are so strong it is not feasible that an infectious dose persists at that range. Similarly, the possibility that air can commute out of one window and into another needs to account for these dilution effects before assumptions of transmission can be drawn. These studies do not sufficiently account for dilution, infectious doses and pathogen survival rates. A more feasible hypothesis is that the Amoy Gardens intra-building spread was through re-aerosolisation of contaminated waste water coming from the faulty plumbing system.

==Institutional Guidance==
The WHO's advice regarding SARS-CoV-2 transmission during clinical interventions is as follows:
''"In the context of COVID-19, airborne transmission may be possible in specific circumstances and settings in which procedures or support treatments that generate aerosols are performed; i.e., endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, turning the patient to the prone position, disconnecting the patient from the ventilator, non-invasive positive-pressure ventilation, tracheostomy, and cardiopulmonary resuscitation."'' - WHO 2020<ref name="WHO 2020" /> 

While the WHO's position acknowledges the increased risk of transmission in overcrowded and under-ventilated spaces, the appropriate response is not to increase prescribed general ventilation rates, but rather to avoid overcrowding and maintain ventilation systems correctly.

The US-CDC's recommendations regarding inpatient accommodation include the comment,
"Experience in some settings in Taiwan and Toronto demonstrated that cohorting SARS patients, without use of AIIRs, effectively interrupted transmission"<ref>US-CDC,2005, https://www.cdc.gov/sars/guidance/i-infection/healthcare.html</ref>

==Engineering Controls==

Without good viability studies of the viral particles found in ventilation systems, no firm guidance can be offered regarding the rate of reduction for SARS-CoV-2 viability with time and distance. Until that time it would be prudent to assume that the virus should only be considered as airborne under special and rare conditions, based on the guidance of the WHO. This would determine that we have different filtration and ventilation approaches between COVID-ICUs, general indoor public spaces and spaces with a potential for high density occupation.

For high-risk spaces it may be prudent to implement temporary measures to limit transmission risk to the minimum possible. In order of priorities, engineering interventions include:

#decongest indoor spaces to the minimum possible occupancy levels
#open windows to outside when occupational health, safety and security are not compromised
#increase HVAC fresh air rates to maximum possible levels
#reduce HVAC recirculation levels to minimum possible levels
#flush buildings with fresh air before and after daily occupancy

The following matrix is intended to guide our design responses for a sample of space types
{| class="wikitable"
|+Risk Response Matrix
!Space Type
!Risk
!Initial Risk
!Engineering Response
!Residual Risk
|-
| rowspan="2" |ICU
|Transmission in ICU
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Low
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Where high risks are associated with adjacent spaces, ventilate ICU in accordance with IUSS Guidelines for Airborne Precaution Rooms
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |Surgeries
|Transmission in Theatre
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs,
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Moderate
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Surgeries on identified COVID-19 patients in containment or sepsis theatres
##No recirculation to adjacent spaces
##Ensure compliance with contact, droplet and airborne precautions for staff
##Where high risks are associated with adjacent spaces, ventilate the operating room in accordance with IUSS Guidelines for Airborne Precaution Rooms or sepsis theatres
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |COVID Wards
|Transmission within COVID-19 Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for general wards
#Keep available windows open when safe and secure
#Ensure compliance with contact, droplet and airborne precautions
|Low
|-
|Transmission to Adjacent spaces
|High
| 

#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
##Increase ventilation rates in adjacent areas (passages)
##Positive pressure relative to COVID wards
##Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
##Extraction systems to discharge safely at high-level
|Low
|-
|General wards
|Transmission within and from Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for General Wards
|Low
|-
|Emergency centre
|Transmission within EC
|High
|
#Reduce number of occupants to only essential staff and caregivers
#Screen and fast-track patients with respiratory illness symptoms
#Isolate persons under investigation for COVID-19
##Isolation rooms ventilated in accordance with IUSS guidance for airborne precaution rooms
|Moderate
|-
|Hospital Waiting Areas
|Transmission within waiting room
|High
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with IUSS Guidelines for Waiting Areas
|Moderate
|-
|Other public waiting spaces
|Transmission within waiting room
|Moderate
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with Building Regulations
|Moderate
|}
Therefore, assuming systems have been designed in accordance with the IUSS guidance, there should be little reason to change their configuration or pressurization unless general areas are repurposed as airborne precaution rooms. Risk assessments should be conducted for ICUs and COVID-19 wards immediately adjacent to public waiting areas or other high traffic areas, with corrective actions including but not limited to reducing occupancy times and rates for these areas.

 
----

==Notes and References==
[[Category:Reference Desk]]
[[Category:COVID-19]]
[[Category:ICU]]
[[Category:Airbone Infection control]]
<references />

Ventilation and COVID-19

2020-07-13T17:13:34Z

Peta:

'''THIS ARTICLE IS STILL BEING ACTIVELY WRITTEN AND EDITED. PLEASE RETURN FOR THE COMPLETED WORK SHORTLY.'''
{{Expand}}
[[Category:COVID-19]]
[[Category:Airborne Contamination Control]]
[[Category:Crosscutting Issues]]

==Background==

===Transmission routes===
SARS-CoV-2 seems to have caused many to rethink their understanding of droplet and airborne transmission. These two transmission mechanisms form a continuum, but the following is generally accepted:

*''Infectious'' particles <5μm in size can remain suspended and viable for many hours and these contribute to the risk of '''airborne transmission'''.
*'''Droplet transmission''' involves larger particles which can also spread through the air for some distance, but the range of transmission is generally considered to be less than 2 meters where after particles fall out of the breathing zone. It is important to remember that within this 2 m distance these larger droplets are essentially 'airborne' and diluting ventilation systems have little effect on reducing the risk of near-range droplet transmission<ref>Liu, L., Li, Y., Nielsen, P. V., Wei, J. & Jensen, R. L. Short-range airborne transmission of expiratory droplets between two people. Indoor Air 1–11 (2016) doi:10.1111/ina.12314.</ref>.

Droplet precautions, therefore, include standard precautions like PPE, hand washing and distancing while airborne precautions include negative pressure isolation, respiratory protection, special exhaust or filtration regimes, etc.

Diseases seldom obey only one mode of transmission (obligatory transmission) but often have preferences (preferential transmission) while occasionally exploiting circumstances which provide rare opportunities for transmission (opportunistic routes). SARS-COV-2 is understood to be '''preferentially droplet and contact spread''' (a form of droplet spread where droplets can settle on fomites) with possible rare and opportunistic airborne spread, although an extensive outbreak review revealed no indication of airborne spread<ref>https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>.

===Airborne Transmission===
There is still little strong evidence of common long-range airborne transmission in the sense of droplet nucleation, as with TB and measles<ref>World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) 16-24 February 2020 [Internet]. Geneva: World Health Organization; 2020 Available from: [https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf]</ref>. Where evidence of airborne transmission has been reported, this can be seen in the context of opportunistic long-range droplet spread<ref> Wenzhao Chen, Nan Zhang, Jianjian Wei, Hui-LingYen, and Yuguo Li, “Short-range airborne route dominates exposure of respiratory infection during close contact,” medRxiv preprint, https://doi.org/10.1101/2020.03.16.20037291</ref>. A discussion contextualizing the reported cases of airborne transmission is discussed below. 

Van Doremalen's SARS-CoV-2 survival study is often incorrectly reported to have shown that SARS-CoV-2 can remain viable in air for extended periods<ref name="van Doremalen">Neeltje van Doremalen, Trenton Bushmaker, Dylan H. Morris, Myndi G. Holbrook, Amandine Gamble, Brandi N. Williamson, Azaibi Tamin, Jennifer L. Harcourt, Natalie J. Thornburg, Susan I. Gerber, James O. LloydSmith, Emmie de Wit, and Vincent J. Munster, “Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1,” The New England Journal of Medicine (2020), DOI: 10.1056/NEJMc2004973 [https://www.nejm.org/doi/pdf/10.1056/NEJMc2004973?articleTools=true]</ref>. No evidence for airborne viability has yet been found outside of lab settings. SARS-CoV-2 virus found dispersed at long range has not been cultured to prove viability and many studies have failed to detect it directly in air in quantities substantial enough to culture<ref>Faridi, S. et al. A field indoor air measurement of SARS-CoV-2 in the patient rooms of the largest hospital in Iran. Sci. Total Environ. 725, 1–5 (2020).</ref><ref>Liu, Y. et al. Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals. Nature (2020) doi:10.1038/s41586-020-2271-3.</ref>. Correlations between culture viability, particle size and the real world infectious quantum were not described in this study<ref name="van Doremalen" /> and it was not the study's intention to claim COVID-19 was airborne. More recent studies have made similar findings<ref>Fears SC, Klimstra WB, Duprex P, Hartman A, Weaver SC, Plante KS, et al. Persistence of severe acute respiratory syndrome coronavirus 2 in aerosol suspensions. Emerg Infect Dis. 2020 Sep [''date cited'']. <nowiki>https://doi.org/10.3201/eid2609.201806</nowiki></ref>. More importantly, similar lab studies have also demonstrated a 3h airborne survival for viral strains not thought to be airborne<ref>Robert Comparison of the Aerosol Stability of 2 Strains of Zaire ebolavirus From the 1976 and 2013 Outbreaks Robert J. Fischer, Trenton Bushmaker, Seth Judson, Vincent J. Munster
J Infect Dis. 2016 Oct 15; 214(Suppl 3): S290–S293. Published online 2016 Oct 4. doi: 10.1093/infdis/jiw193 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5050463/</ref>. This makes the direct application of this lab study in real-world settings problematic. 

Therefore, the understanding of the mechanisms of COVID-19 transmission is still largely reliant on what is understood of SARS (SARS-CoV-1)<ref>Isao Arita, Kazunobu Kojima, and Miyuki Nakane, “Transmission of severe acute respiratory syndrome,” Emerging. Infectious Diseases 9 No. 9 (2003):1183-84, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016764/].</ref> The CDC's advice regarding SARS-CoV-2 transmission is still nearly identical to it's guidance for SARS-CoV-1:
''"The primary transmission of COVID-19 is from person-to-person through respiratory droplets. These droplets are released when someone with COVID-19 sneezes or coughs. COVID-19 can also be spread when you are in close contact with someone who is sick (e.g., shaking hands or talking). A physical distance of at least 1 meter (3ft) between persons is suggested by the World Health Organization (WHO) to avoid infection, although some WHO member states have recommended maintaining greater distances whenever possible. Respiratory droplets can land on objects or surfaces around the person when they cough or talk, and people can then become infected with COVID-19 from touching these objects or surfaces and then touching their eyes, nose or mouth. Recent data suggests that there can be transmission of COVID-19 through droplets of those with mild symptoms or those who do not feel ill"'' <ref>https://www.cdc.gov/sars/about/faq.html</ref><ref>https://www.cdc.gov/sars/about/faq.html</ref>

Studies which have found real-world SARS-CoV-2 in air, ducting and on extraction fans have so far failed to prove that the virus found was still viable<ref>Santarpia et al, “Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center,. medRxiv preprint (2020), [https://doi.org/10.1101/2020.03.23.20039446]</ref><ref>Po Ying Chia et al, 2020 (Preprint) “Detection of Air and Surface Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in Hospital Rooms of Infective Patients,” medRxiv preprint (2020), https://doi.org/10.1101/2020.03.29.20046557 [https://www.medrxiv.org/content/10.1101/2020.03.29.20046557v2.full.pdf]</ref>. It has been suggested that high temperature and humidity would reduce the spread of the virus<ref>Chin, A. W. H. et al. Stability of SARS-CoV-2 in different environmental conditions. The Lancet Microbe 0–4 (2020) doi:10.1016/s2666-5247(20)30003-3.</ref><ref>Pyankov, O. V., Bodnev, S. A., Pyankova, O. G. & Agranovski, I. E. Survival of aerosolized coronavirus in the ambient air. J. Aerosol Sci. 115, (2018).</ref>. The temperature ranges suggested (>50°C) are beyond what anyone could endure in an ICU but the humidity ranges of between 40-60% are achievable. The high humidity slows the nucleation of the viral droplet and increases its settling speed, thereby reducing its range.

====High Risk Settings====
Much of the work being done to understand the transmission mechanism of COVID-19 is focused on community transmission. It is important to remember that transmission risk in an ICU will not be the same as in homes and workplaces. The conditions and procedures in ICUs could promote transmission<see WHO 2020 below<ref name="WHO 2020">WHO 2020, Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>. Firstly, in a COVID ICU unit, the contamination source strength is much higher than other spaces since infected patients are congregated there. These are presumably ill patients with high viral shedding. Secondly, procedures like intubation are understood to release high quantities of aerosolized particles, unlike with general talking or coughing. Additionally, viral shedding through talking and coughing can be more readily mitigated than from intubation.

===Fecal-Oral Transmission===
Fecal oral route of transmission is acknowledged for COVID-19<ref>Pan Y, Zhang D, Yang P, Poon LLM, Wang Q. Viral load of SARS-CoV-2 in clinical samples. Lancet Infect Dis. 2020;20(4):411-2.</ref> and considerations for waste water management are discussed [[SARS-CoV-2 is found in faecal matter|here]].

This transmission route indirectly affects ventilation system design as special consideration should be given to common scenarios where the aerosolisation of contaminated wastewater is a possibility such as in bathrooms, sluice rooms and slurry pumping. These spaces should be well-ventilated and kept under negative pressure relative to adjacent spaces.

====A Note on ''Amoy Gardens'' SARS studies<ref>McKinney KR, Gong YY, Lewis TG. Environmental transmission of SARS at Amoy Gardens. ''J Environ Health''. 2006;68(9):26-52.</ref>====
Studies, which indicate the Amoy Gardens building's SARS outbreaks' transmission was via the airborne route, commonly reference the prevailing wind between buildings. It should be noted that, since these buildings are about 60m apart the environmental dilution and concentration decay effects are so strong it is not feasible that an infectious dose your persist at that range. Similarly, the possibility that air can commute out of one window and into another needs to account for these dilution effects before assumptions of transmission can be drawn. These studies do not sufficiently account for dilution, infectious doses and pathogen survival rates. A more feasible hypothesis is that the Amoy Gardens intra-building spread was through re-aerosolisation of contaminated waste water coming from the faulty plumbing system.

==Institutional Guidance==
The WHO's advice regarding SARS-CoV-2 transmission during clinical interventions is as follows:
''"In the context of COVID-19, airborne transmission may be possible in specific circumstances and settings in which procedures or support treatments that generate aerosols are performed; i.e., endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, turning the patient to the prone position, disconnecting the patient from the ventilator, non-invasive positive-pressure ventilation, tracheostomy, and cardiopulmonary resuscitation."'' - WHO 2020<ref name="WHO 2020" /> 

While the WHO's position acknowledges the increased risk of transmission in overcrowded and under-ventilated spaces, the appropriate response is not to increase prescribed general ventilation rates, but rather to avoid overcrowding and maintain ventilation systems correctly.

The US-CDC's recommendations regarding inpatient accommodation include the comment,
"Experience in some settings in Taiwan and Toronto demonstrated that cohorting SARS patients, without use of AIIRs, effectively interrupted transmission"<ref>US-CDC,2005, https://www.cdc.gov/sars/guidance/i-infection/healthcare.html</ref>

==Engineering Controls==

Without good viability studies of the viral particles found in ventilation systems, no firm guidance can be offered regarding the rate of reduction for SARS-CoV-2 viability with time and distance. Until that time it would be prudent to assume that the virus should only be considered as airborne under special and rare conditions, based on the guidance of the WHO. This would determine that we have different filtration and ventilation approaches between COVID-ICUs, general indoor public spaces and spaces with a potential for high density occupation.

For high-risk spaces it may be prudent to implement temporary measures to limit transmission risk to the minimum possible. In order of priorities, engineering interventions include:

#decongest indoor spaces to the minimum possible occupancy levels
#open windows to outside when occupational health, safety and security are not compromised
#increase HVAC fresh air rates to maximum possible levels
#reduce HVAC recirculation levels to minimum possible levels
#flush buildings with fresh air before and after daily occupancy

The following matrix is intended to guide our design responses for a sample of space types
{| class="wikitable"
|+Risk Response Matrix
!Space Type
!Risk
!Initial Risk
!Engineering Response
!Residual Risk
|-
| rowspan="2" |ICU
|Transmission in ICU
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Low
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Where high risks are associated with adjacent spaces, ventilate ICU in accordance with IUSS Guidelines for Airborne Precaution Rooms
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |Surgeries
|Transmission in Theatre
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs,
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Moderate
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Surgeries on identified COVID-19 patients in containment or sepsis theatres
##No recirculation to adjacent spaces
##Ensure compliance with contact, droplet and airborne precautions for staff
##Where high risks are associated with adjacent spaces, ventilate the operating room in accordance with IUSS Guidelines for Airborne Precaution Rooms or sepsis theatres
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |COVID Wards
|Transmission within COVID-19 Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for general wards
#Keep available windows open when safe and secure
#Ensure compliance with contact, droplet and airborne precautions
|Low
|-
|Transmission to Adjacent spaces
|High
| 

#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
##Increase ventilation rates in adjacent areas (passages)
##Positive pressure relative to COVID wards
##Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
##Extraction systems to discharge safely at high-level
|Low
|-
|General wards
|Transmission within and from Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for General Wards
|Low
|-
|Emergency centre
|Transmission within EC
|High
|
#Reduce number of occupants to only essential staff and caregivers
#Screen and fast-track patients with respiratory illness symptoms
#Isolate persons under investigation for COVID-19
##Isolation rooms ventilated in accordance with IUSS guidance for airborne precaution rooms
|Moderate
|-
|Hospital Waiting Areas
|Transmission within waiting room
|High
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with IUSS Guidelines for Waiting Areas
|Moderate
|-
|Other public waiting spaces
|Transmission within waiting room
|Moderate
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with Building Regulations
|Moderate
|}
Therefore, assuming systems have been designed in accordance with the IUSS guidance, there should be little reason to change their configuration or pressurization unless general areas are repurposed as airborne precaution rooms. Risk assessments should be conducted for ICUs and COVID-19 wards immediately adjacent to public waiting areas or other high traffic areas, with corrective actions including but not limited to reducing occupancy times and rates for these areas.

 
----

==Notes and References==
[[Category:Reference Desk]]
[[Category:COVID-19]]
[[Category:ICU]]
[[Category:Airbone Infection control]]
<references />

Ventilation and COVID-19

2020-07-13T17:08:53Z

Peta: /* Background */

'''THIS ARTICLE IS STILL BEING ACTIVELY WRITTEN AND EDITED. PLEASE RETURN FOR THE COMPLETED WORK SHORTLY.'''
{{Expand}}
[[Category:COVID-19]]
[[Category:Airborne Contamination Control]]
[[Category:Crosscutting Issues]]

==Background==

===Transmission routes===
SARS-CoV-2 seems to have caused many to rethink their understanding of droplet and airborne transmission. These two transmission mechanisms form a continuum, but the following is generally accepted:

*''Infectious'' particles <5μm in size can remain suspended and viable for many hours and these contribute to the risk of '''airborne transmission'''.
*'''Droplet transmission''' involves larger particles which can also spread through the air for some distance, but the range of transmission is generally considered to be less than 2 meters where after particles fall out of the breathing zone. It is important to remember that within this 2 m distance these larger droplets are essentially 'airborne' and diluting ventilation systems have little effect on reducing the risk of near-range droplet transmission<ref>Liu, L., Li, Y., Nielsen, P. V., Wei, J. & Jensen, R. L. Short-range airborne transmission of expiratory droplets between two people. Indoor Air 1–11 (2016) doi:10.1111/ina.12314.</ref>.

Droplet precautions, therefore, include standard precautions like PPE, hand washing and distancing while airborne precautions include negative pressure isolation, respiratory protection, special exhaust or filtration regimes, etc.

Diseases seldom obey only one mode of transmission (obligatory transmission) but often have preferences (preferential transmission) while occasionally exploiting circumstances which provide rare opportunities for transmission (opportunistic routes). SARS-COV-2 is understood to be '''preferentially droplet and contact spread''' (a form of droplet spread where droplets can settle on fomites) with possible rare and opportunistic airborne spread, although an extensive outbreak review revealed no indication of airborne spread<ref>https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>.

===Airborne Transmission===
There is still little strong evidence of common long-range airborne transmission in the sense of droplet nucleation, as with TB and measles<ref>World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) 16-24 February 2020 [Internet]. Geneva: World Health Organization; 2020 Available from: [https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf]</ref>. Where evidence of airborne transmission has been reported, this can be seen in the context of opportunistic long-range droplet spread<ref> Wenzhao Chen, Nan Zhang, Jianjian Wei, Hui-LingYen, and Yuguo Li, “Short-range airborne route dominates exposure of respiratory infection during close contact,” medRxiv preprint, https://doi.org/10.1101/2020.03.16.20037291</ref>. A discussion contextualizing the reported cases of airborne transmission is discussed below. 

Van Doremalen's SARS-CoV-2 survival study is often incorrectly reported to have shown that SARS-CoV-2 can remain viable in air for extended periods<ref name="van Doremalen">Neeltje van Doremalen, Trenton Bushmaker, Dylan H. Morris, Myndi G. Holbrook, Amandine Gamble, Brandi N. Williamson, Azaibi Tamin, Jennifer L. Harcourt, Natalie J. Thornburg, Susan I. Gerber, James O. LloydSmith, Emmie de Wit, and Vincent J. Munster, “Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1,” The New England Journal of Medicine (2020), DOI: 10.1056/NEJMc2004973 [https://www.nejm.org/doi/pdf/10.1056/NEJMc2004973?articleTools=true]</ref>. No evidence for airborne viability has yet been found outside of lab settings. SARS-CoV-2 virus found dispersed at long range has not been cultured to prove viability and many studies have failed to detect it directly in air in quantities substantial enough to culture<ref>Faridi, S. et al. A field indoor air measurement of SARS-CoV-2 in the patient rooms of the largest hospital in Iran. Sci. Total Environ. 725, 1–5 (2020).</ref><ref>Liu, Y. et al. Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals. Nature (2020) doi:10.1038/s41586-020-2271-3.</ref>. Correlations between culture viability, particle size and the real world infectious quantum were not described in this study<ref name="van Doremalen" /> and it was not the study's intention to claim COVID-19 was airborne. More recent studies have made similar findings<ref>Fears SC, Klimstra WB, Duprex P, Hartman A, Weaver SC, Plante KS, et al. Persistence of severe acute respiratory syndrome coronavirus 2 in aerosol suspensions. Emerg Infect Dis. 2020 Sep [''date cited'']. <nowiki>https://doi.org/10.3201/eid2609.201806</nowiki></ref>. More importantly, similar lab studies have also demonstrated a 3h airborne survival for viral strains not thought to be airborne<ref>Robert Comparison of the Aerosol Stability of 2 Strains of Zaire ebolavirus From the 1976 and 2013 Outbreaks Robert J. Fischer, Trenton Bushmaker, Seth Judson, Vincent J. Munster
J Infect Dis. 2016 Oct 15; 214(Suppl 3): S290–S293. Published online 2016 Oct 4. doi: 10.1093/infdis/jiw193 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5050463/</ref>. This makes the direct application of this lab study in real-world settings problematic. 

Therefore, the understanding of the mechanisms of COVID-19 transmission is still largely reliant on what is understood of SARS (SARS-CoV-1)<ref>Isao Arita, Kazunobu Kojima, and Miyuki Nakane, “Transmission of severe acute respiratory syndrome,” Emerging. Infectious Diseases 9 No. 9 (2003):1183-84, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016764/].</ref> The CDC's advice regarding SARS-CoV-2 transmission is still nearly identical to it's guidance for SARS-CoV-1:
''"The primary transmission of COVID-19 is from person-to-person through respiratory droplets. These droplets are released when someone with COVID-19 sneezes or coughs. COVID-19 can also be spread when you are in close contact with someone who is sick (e.g., shaking hands or talking). A physical distance of at least 1 meter (3ft) between persons is suggested by the World Health Organization (WHO) to avoid infection, although some WHO member states have recommended maintaining greater distances whenever possible. Respiratory droplets can land on objects or surfaces around the person when they cough or talk, and people can then become infected with COVID-19 from touching these objects or surfaces and then touching their eyes, nose or mouth. Recent data suggests that there can be transmission of COVID-19 through droplets of those with mild symptoms or those who do not feel ill"'' <ref>https://www.cdc.gov/sars/about/faq.html</ref><ref>https://www.cdc.gov/sars/about/faq.html</ref>

Studies which have found real-world SARS-CoV-2 in air, ducting and on extraction fans have so far failed to prove that the virus found was still viable<ref>Santarpia et al, “Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center,. medRxiv preprint (2020), [https://doi.org/10.1101/2020.03.23.20039446]</ref><ref>Po Ying Chia et al, 2020 (Preprint) “Detection of Air and Surface Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in Hospital Rooms of Infective Patients,” medRxiv preprint (2020), https://doi.org/10.1101/2020.03.29.20046557 [https://www.medrxiv.org/content/10.1101/2020.03.29.20046557v2.full.pdf]</ref>. It has been suggested that high temperature and humidity would reduce the spread of the virus<ref>Chin, A. W. H. et al. Stability of SARS-CoV-2 in different environmental conditions. The Lancet Microbe 0–4 (2020) doi:10.1016/s2666-5247(20)30003-3.</ref><ref>Pyankov, O. V., Bodnev, S. A., Pyankova, O. G. & Agranovski, I. E. Survival of aerosolized coronavirus in the ambient air. J. Aerosol Sci. 115, (2018).</ref>. The temperature ranges suggested (>50°C) are beyond what anyone could endure in an ICU but the humidity ranges of between 40-60% are achievable. The high humidity slows the nucleation of the viral droplet and increases its settling speed, thereby reducing its range.

====High Risk Settings====
Much of the work being done to understand the transmission mechanism of COVID-19 is focused on community transmission. It is important to remember that transmission risk in an ICU will not be the same as in homes and workplaces. The conditions and procedures in ICUs could promote transmission<see WHO 2020 below<ref name="WHO 2020">WHO 2020, Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>. Firstly, in a COVID ICU unit, the contamination source strength is much higher than other spaces since infected patients are congregated there. These are presumably ill patients with high viral shedding. Secondly, procedures like intubation are understood to release high quantities of aerosolized particles, unlike with general talking or coughing. Additionally, viral shedding through talking and coughing can be more readily mitigated than from intubation.

===Fecal-Oral Transmission===
Fecal oral route of transmission is acknowledged for COVID-19<ref>Pan Y, Zhang D, Yang P, Poon LLM, Wang Q. Viral load of SARS-CoV-2 in clinical samples. Lancet Infect Dis. 2020;20(4):411-2.</ref> and considerations for waste water management are discussed [[SARS-CoV-2 is found in faecal matter|here]].

This transmission route indirectly affects ventilation system design as special consideration should be given to common scenarios where the aerosolisation of contaminated wastewater is a possibility such as in bathrooms, sluice rooms and slurry pumping. These spaces should be well-ventilated and kept under negative pressure relative to adjacent spaces.

====A Note on ''Amoy Gardens'' SARS studies<ref>McKinney KR, Gong YY, Lewis TG. Environmental transmission of SARS at Amoy Gardens. ''J Environ Health''. 2006;68(9):26-52.</ref>====
Studies, which indicate the Amoy Gardens building's SARS outbreaks' transmission was via the airborne route, commonly reference the prevailing wind between buildings. It should be noted that, since these buildings are about 60m apart the environmental dilution and concentration decay effects are so strong it is not feasible that an infectious dose your persist at that range. Similarly, the possibility that air can commute out of one window and into another needs to account for these dilution effects before assumptions of transmission can be drawn. These studies do not sufficiently account for dilution, infectious doses and pathogen survival rates. A more feasible hypothesis is that the Amoy Gardens intra-building spread was through re-aerosolisation of contaminated waste water coming from the faulty plumbing system.

==Institutional Guidance==
The WHO's advice regarding SARS-CoV-2 transmission during clinical interventions is as follows:
''"In the context of COVID-19, airborne transmission may be possible in specific circumstances and settings in which procedures or support treatments that generate aerosols are performed; i.e., endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, turning the patient to the prone position, disconnecting the patient from the ventilator, non-invasive positive-pressure ventilation, tracheostomy, and cardiopulmonary resuscitation."'' - WHO 2020<ref name="WHO 2020" /> 

While the WHO's position acknowledges the increased risk of transmission in overcrowded and under-ventilated spaces, the appropriate response is not to increase prescribed general ventilation rates, but rather to avoid overcrowding and maintain ventilation systems correctly.

The US-CDC's recommendations regarding inpatient accommodation include the comment,
"Experience in some settings in Taiwan and Toronto demonstrated that cohorting SARS patients, without use of AIIRs, effectively interrupted transmission"<ref>US-CDC,2005, https://www.cdc.gov/sars/guidance/i-infection/healthcare.html</ref>

==Engineering Controls==

Without good viability studies of the viral particles found in ventilation systems, no firm guidance can be offered regarding the rate of reduction for SARS-CoV-2 viability with time and distance. Until that time it would be prudent to assume that the virus should only be considered as airborne under special and rare conditions, based on the guidance of the WHO. This would determine that we have different filtration and ventilation approaches between COVID-ICUs, general indoor public spaces and spaces with a potential for high density occupation.

For high-risk spaces it may be prudent to implement temporary measures to limit transmission risk to the minimum possible. In order of priorities, engineering interventions include:

#decongest indoor spaces to the minimum possible occupancy levels
#open windows to outside when occupational health, safety and security are not compromised
#increase HVAC fresh air rates to maximum possible levels
#reduce HVAC recirculation levels to minimum possible levels
#flush buildings with fresh air before and after daily occupancy

The following matrix is intended to guide our design responses for a sample of space types
{| class="wikitable"
|+Risk Response Matrix
!Space Type
!Risk
!Initial Risk
!Engineering Response
!Residual Risk
|-
| rowspan="2" |ICU
|Transmission in ICU
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Low
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Where high risks are associated with adjacent spaces, ventilate ICU in accordance with IUSS Guidelines for Airborne Precaution Rooms
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |Surgeries
|Transmission in Theatre
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs,
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Moderate
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Surgeries on identified COVID-19 patients in containment or sepsis theatres
##No recirculation to adjacent spaces
##Ensure compliance with contact, droplet and airborne precautions for staff
##Where high risks are associated with adjacent spaces, ventilate the operating room in accordance with IUSS Guidelines for Airborne Precaution Rooms or sepsis theatres
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |COVID Wards
|Transmission within COVID-19 Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for general wards
#Keep available windows open when safe and secure
#Ensure compliance with contact, droplet and airborne precautions
|Low
|-
|Transmission to Adjacent spaces
|High
| 

#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
##Increase ventilation rates in adjacent areas (passages)
##Positive pressure relative to COVID wards
##Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
##Extraction systems to discharge safely at high-level
|Low
|-
|General wards
|Transmission within and from Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for General Wards
|Low
|-
|Emergency centre
|Transmission within EC
|High
|
#Reduce number of occupants to only essential staff and caregivers
#Screen and fast-track patients with respiratory illness symptoms
#Isolate persons under investigation for COVID-19
##Isolation rooms ventilated in accordance with IUSS guidance for airborne precaution rooms
|Moderate
|-
|Hospital Waiting Areas
|Transmission within waiting room
|High
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with IUSS Guidelines for Waiting Areas
|Moderate
|-
|Other public waiting spaces
|Transmission within waiting room
|Moderate
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with Building Regulations
|Moderate
|}
Therefore, assuming systems have been designed in accordance with the IUSS guidance, There should be little reason to change their configuration or pressurization unless general areas are repurposed as airborne precaution rooms. Risk assessments should be conducted for ICUs and COVID-19 wards immediately adjacent to public waiting areas or other high traffic areas, with corrective actions including but not limited to reducing occupancy times and rates for these areas.

 
----

==Notes and References==
[[Category:Reference Desk]]
[[Category:COVID-19]]
[[Category:ICU]]
[[Category:Airbone Infection control]]
<references />

Infection Prevention and Control/Surface Decontamination

2020-06-25T10:31:49Z

Peta: /* Decontamination */

[[Infection Prevention and Control/Air Disinfection| Return to Air Disinfection]]

==Decontamination==
Decontamination is the process of making an area safe by removing, neutralising or destroying any harmful substances. Decontamination can be achieved by applying physical agents, chemical agents or mechanical removal through any combination of cleaning, disinfection or sterilisation. Physical agents could include heat, radiation and chemical agents include a myriad gasses and liquids.
===Cleaning===
Cleaning is the process of achieving a state where an area is visually free of contaminating debris. Cleaning is generally achieved by the application of mechanical removal and liquid chemical agents. Cleaning is often an initial decontamination process which removes organic matter from an area. Such organic matter can promote microbial growth and protect microorganisms during further decontamination stages such as disinfection or sterilisation. Cleaning is also frequently applied as the final decontamination stage during which inactivated microorganisms or residual toxins are removed from an area.
===Disinfection===
Disinfection is the decontamination process of reducing the number of infectious agents to the level where they no longer cause disease. Disinfection typically does not remove bacterial spores.
===Sterilisation===
Sterilisation is any decontamination process which removes or kills all forms of life in an area. This includes viruses, bacteria, funguses and spores forming organisms.

==Surface Decontamination by Cleaning==
Before cleaning, a strategy must be available which identifies target organisms, areas, processes, tools and chemical agents appropriate to the area. A review of the high touch areas in the space will inform the strategy. The selection of chemical agents should be based on their intended function (rates of cleaning or disinfection) and the resistance of the target surfaces to potentially corrosive agents. A final cleaning should be done with chemical agents and tools that remove residues from other processes leave no additional unwanted residues.
==Surface Decontamination by Heat==
Decontamination by heat is typically a sterilisation process with some measure of cleaning beforehand. Surface decontamination by heat is not a common practice and the temperature/time dose function typically requires long exposure times due to the low heat tolerance of surfaces. 
Two heat sterilisation processes are available, wet and dry heat. 
'''Wet heat''' is considered the most dependable method of sterilisation. Steam sterilisers or autoclaves apply heat and humidity under pressure (using saturated steam at 121 °C and 104 kPa) to sterilise laboratory and medical equipment. The application of steam allows for better penetration of heat through permeable insulating layers on any surface than dry heat alone. Autoclaves are occasionally used to sterilise infectious waste. 
'''Dry heat''' sterilisation is less dependable than wet heat as layers of debris on a surface can insulate organic materials from the process. Dry heat sterilisation is appropriate for impermeable surfaces like glass, but higher temperatures and exposure times are required (160 – 170 °C for periods of 120 to 240 minutes).

==Surface Decontamination by Chemicals==
{{stub}}

==Surface Decontamination by Irradiation==
Ionising and non-ionising irradiation are both able to decontaminate surfaces. Ionising radiation is not considered generally safe and practical for surface decontamination in a clinical or laboratory setting. Non-ionising radiation such as ultraviolet light in the UV-C band effectively inactivates most microorganisms on surfaces and in the air.

===Surface Decontamination by Ultraviolet Germicidal Irradiation===
The disinfection effect of ultraviolet light has been described for over 100 years<ref> Downes, Arthur; Blunt, Thomas P. (19 December 1878). https://royalsocietypublishing.org/doi/pdf/10.1098/rspl.1878.0109</ref>. It is effective against a variety of microorganisms and has been successfully deployed for the purpose of disinfection of water, air and surfaces. Effectiveness depends on a range of variables related to the microorganism of interest, environment and application. Ultraviolet radiation in the UV-C range has been used for its germicidal properties specifically for infection prevention and control - have been demonstrated to work at laboratory scale, in ducts, as upper room irradiation and as portable devices. Safety guidelines have been established (ACGIH)<ref name="cite">Citation Needed</ref>. 

UVGI surface disinfection has advantages over chemical disinfection because:

*There is no off-gassing of chemicals or residual chemical contamination frequently associated with chemical-based disinfection methods. Therefore, vehicles or spaces can be occupied immediately after UVGI disinfection<ref name="Kowalski 2009">Wladyslaw Kowalski, 2009. Ultraviolet Germicidal Irradiation Handbook: UVGI for Air and Surface Disinfection. New York. Springer. [https://www.springer.com/gp/book/9783642019982]</ref>;
*It has high pathogen reduction rates when compared to chemical cleaning; and
*Chemical disinfection methods are time-consuming <ref name="Kostyuchenko 2009">Sergey Kostyuchenko, Anna Khan, Sergey Volkov, Henk Giller, 2009. UV Disinfection in Moscow Metro Public Transport Systems. IUVA News / Vol. 11 No. 1 [https://iuvanews.com/stories/pdf/archives/110101KostyuchenkoEtAl_Article.pdf]</ref>.

A guideline on hospital infection control <ref name="Brown 1996">Brown IW Jr et al (1996) Toward further reducing wound infections in cardiac operations. Ann Thorac Surg 62(6):1783–1789.[https://www.ncbi.nlm.nih.gov/pubmed/8957387]</ref><ref name="Shamim 2017">Shamim, I. A. ed., 2017. Ultraviolet Light in Human Health, Diseases and Environment. Cham, Switzerland: Springer International Publishing AG.[https://www.springer.com/gp/book/9783319560168]</ref> recommends the use of both UVGI and chemical disinfection since UVGI has no penetrating power on dust, dirt and grease, which may harbour microbial contamination. Exposure to UV-C may degrade some materials. 

For UVGI surface disinfection for SARC-CoV-2, refer to [[Infrastructure_Guidance_for_COVID-19/COVID-19_Infection_Prevention_and_Control#Ultraviolet_Surface_Disinfection_for_SARS-CoV-2|COVID-19 infection control guidance]]
The effective band of germicidal ultraviolet (GUV) radiation is between wavelengths of 250-270 nm with 265 nm the optimum efficiency. Ultraviolet Germicidal Irradiation effectively destroys most microorganisms on surfaces. Dirt, dust, and shadows can shield organisms which must be directly exposed to the GUV light. This and safety concerns are limiting factors for its general application. 

The application of UVGI for surface disinfection usually involves the use of bare UVGI lamps. Two main approaches to surface disinfection systems are via permanently installed disinfection systems and portable disinfection systems. Permanently installed systems generally consist of bare UVGI lamp fixtures mounted on ceilings or walls. Portable UVGI systems are moved into a place temporarily to decontaminate surfaces <ref name="Kowalski 2009" />.
Efficacy is dependent on the intensity of irradiation emitted from the device, proximity of the device to the surface being disinfected and exposure time. The reflectivity of the materials in the vicinity of exposure can increase or decrease efficacy. Shaded items not directly exposed to UV-C irradiation may not effectively be disinfected
----
====UVGI Efficacy====

:'''UVGI dose'''

The UV-C dose required to achieve a particular pathogen reduction rate is calculated from the single-stage decay equation:
S=e-kD
where: 

;*S is the Survival fractional [%] 
;*k is the UVGI rate constant [m2/J] 
;*D is the UVGI exposure dose [J/m2] 

The required UVGI dose for a 4 log reduction (99.99% pathogen reduction rate) is calculated by expressing the single-stage decay equation as follows:
ln(''⁡S'')=-''k''·''D''·ln(⁡''e'')
∴''D'' = (ln (⁡0.0001))/(-k) '' mJ/cm2'' ''(J/cm2)''
----
====UVGI Validation====
Validation testing for UVGI surface disinfecting systems is required to ensure that the UV dose for ≥99.99% level of pathogen inactivation is achieved. As the dose rate is a function of the UV sources output and its distance to the target, the manufacturer for non-static UVGI surface disinfecting systems should specify the design minimum distance away from a surface, the UVGI intensity on the surface and the time required to achieve ≥99.99% pathogen reduction. 
For disinfection that has either dynamic source or target components, repeatability and confidence studies are required to ensure that the range of variability expected does not exceed acceptable limits for efficacy and safety

====UVGI Safety====
Studies of personnel practising proper UVGI exposure control measures have shown no harmful effects<ref name="Brown 1996" />, <ref name="Shamim 2017" /> . Noncompliance with safety precautions can lead to injuries <ref name="Shamim 2017" />. The following safety issues are associated with the handling of UV equipment. 
UV radiation exposure present hazards to the skin and the eyes <ref name="Kowalski 2009" /> <ref name="Myung 2005">Myung C. J., 2005. Ultraviolet (UV) Radiation Safety. Environmental Health and Safety University of Nevada Reno. [https://www.unr.edu/ehs/program-areas/radiation-safety/ultraviolet]</ref>.

=====UVGI Exposure Guidelines=====
The ability of UV radiation to penetrate the eyes and skin depends on the wavelength, therefore the UV radiation exposure Threshold Limit Values (TLV) for the eyes and skin published by the American Conference of Governmental Industrial Hygienists (ACGIH) <ref name="ACGIH" /> also varies according to the UV wavelength. For UVGI at 254 nm, a cumulative exposure dose greater than 6mJ/cm2 <ref name="ACGIH" /> is considered harmful to eyes and skin. Since UVGI surface disinfection systems use bare lamps with dose requirements exceeding 6 mJ/cm2, adherence to PPE is highly recommended to avoid harm.

=====Eye Safety=====
The UV wavelength is the determining factor as to which part(s) of the eye may absorb the radiation and suffer biological effects. 
The table below shows the absorption of different UV wavelengths by the human eye. 
{| class="wikitable"
|+Absorption of UV wavelengths in the Human Eye <ref name="Myung 2005" />
!Wavelength {nm}!!Cornea!!Aqueous!!Lens!!Vitreous
|-
|100-280||100%||0%||0%||0%
|-
|300||92%||6%||2%||0%
|-
|320||45%||16%||36%||1%
|-
|340||37%||14%||48%||1%
|-
|360||34%||12%||52%||2%
|}

UVGI (UV wavelengths 200 to 280nm) cumulative exposure dose greater than 6mJ/cm2 <ref name="ACGIH">American Conference of Governmental Industrial Hygienists (ACGIH), 2019. Threshold Limit Values for Chemical Substances and Physical Agents and Biological Exposure Indices. ACGIH: USA [https://www.acgih.org/forms/store/ProductFormPublic/2019-tlvs-and-beis-with-7th-edition-documentation-cd-rom-single-user-version]</ref> can cause temporary corneal injuries (photokeratitis and conjunctivitis <ref name="Kowalski 2009" />). Symptoms of corneal injuries (extreme pain in the eyes) present after 6 -12 hours of exposure and lasts for a few days during which corneal cells will recuperate <ref name="Kowalski 2009" /><ref name="Shamim 2017" />.

=====Skin Safety=====
Because of poor penetration and absorption capability <ref name="Brown 1996" />, UVGI cannot penetrate or cause permanent harm to human skin <ref name="Myung 2005" />. Some skin irritation or [https://en.wikipedia.org/wiki/Erythema erythema] may be experienced but this will generally clear up with proper care.

====UV control measures====
=====Administrative controls=====
Prevent unauthorized personnel from entering the UV radiation area.
=====Personal protective equipment (PPE)=====
Personal protective equipment (PPE) protects the wearer from harm due to UV radiation exposure. The following PPE should be worn when operating UVGI surface disinfection systems:

:#Plastic goggles with side shields;
:#Head, neck and face covering opaque to UV radiation;
:#Soft cotton gloves and.
:#Long-sleeved, tightly woven fabrics with SPF 15 or greater.

====Burn safety====
UV lamps, depending on the lamp technology, may operate at up to 900°C. The UV lamps and sleeves should be allowed to properly cool down before maintenance to minimize the risk of burns. The electrical equipment (e.g., ballasts) may also become hot during operation and should be evaluated prior to maintenance <ref name="Bolton 2008">Bolton, J.R., Cotton, C.A., 2008. The Ultraviolet Disinfection Handbook. Springer 2008. [https://link.springer.com/book/10.1007%2F978-3-642-01999-9]</ref>.

====Lamp breakage issues and mercury exposure====
UV lamps pose two safety hazards if broken; the lamps and sleeves are constructed of quartz that, when broken, can pose a risk of serious cuts, and UV lamps contain mercury that can create an inhalation or contact hazard <ref name="Bolton 2008" />.

====UV-C effects on materials====
UV radiation that is incident upon a surface can be transmitted, reflected or absorbed <ref name="Shamim 2017" />. Absorption of UV causes photodegradation that result in an alteration to the colour, texture or mechanical properties of the materials <ref name="Shamim 2017" />. Materials with high UV absorption indicate greater potential for photodegradation while those with high reflectivity indicate protective effects <ref name="Kowalski 2009" />. All metals do not experience damage under UV exposure <ref name="Kowalski 2009" />. Some of the materials that experience photodegradation are wood, plastic, Polyvinyl chloride (PVC), fabrics, paint and glass <ref name="Kowalski 2009" />.

Because UV-C is absorbed in the ozone layer in the atmosphere and is material exposure is uncommon, published data on degradation by UV-C is minimal<ref name="UV Solutions"> https://uvsolutionsmag.com/articles/2019/uv-degradation-effects-in-materials-an-elementary-overview/ (Accessed 2020 May 12)</ref>. Nonetheless, UV light is linked with possible material degradation; degrade paint, yellow plastics, and destroy air filters.
Metals are almost entirely unaffected by UV, ceramics are completely unaffected by UV exposure but most polymers are susceptible to degradation by UV-C exposure<ref name="UV Solutions" />. The degradation of polymers can in-turn deteriorate the aesthetic properties such as colour and texture and release by-products into the surrounding environment (outgassing) which may raise additional concern on human health.

===Maintenance and monitoring===
Proper maintenance and monitoring of UVGI surface disinfection systems ensure continued efficacy. Maintenance tasks and their frequencies are shown in the table below.

{| class="wikitable"
|+Maintenance tasks for UVGI surface disinfection system
|-
!Task!!Frequency!!Action
|-
|Check lamp run time values||Monthly||Change lamps if operating hours exceeded design life of 9–10 thousand hours <ref name="Kowalski 2009" />
|-
|Check intensity of UV lamps||Bimonthly||Replace lamps when UVGI dose is equal to or less than the validated UVGI dose after verifying that this condition is caused by low lamp output.
|-
|Visually inspect bulbs to ensure all bulbs are operational.||Weekly||If the bulbs show visual dust accumulation, they should be cleaned. Lamps can be wiped clean with a cloth dampened with water or a cleaning agent like dilute alcohol <ref name="Kowalski 2009" />
|}

The surface UVGI system should be equipped with sensors that automatically monitor UV intensity, validated UV dose and lamps status. A decision chart for UVGI surface disinfection system monitoring is shown below.
[[File:Decision chart for UVGI surface disinfection system monitoring.png|600px|thumb|none|Decision chart for UVGI surface disinfection system monitoring]]

===UVGI lamps disposal===
LPMV lamp contains mercury which is a toxic heavy metal which cycles through the soil, water and atmosphere in the environment.
Send spent lamps to a mercury recycling facility or back to the manufacturer to prevent personal or environmental exposure.

===Training===
Operators designated to care for the UVGI systems should receive adequate training in both UV system theory, operation, maintenance and safety.
----

===Case Studies===
====Moscow trains====
In Moscow, Russia, Kostyuchenko, et. al., <ref name="Kostyuchenko 2009" />, investigated the potential of UVGI disinfection on internal surfaces of train carriages and on escalator handrails. They found that the required UV doses for effective disinfection are higher than the theoretically calculated doses. 

====Ambulance decontamination <ref name="cite" />====

====Respiratory Protective Equipment decontamination <ref name="cite" />====

===Elements of a successful UVGI Disinfection Program===
====Messaging====
It is important for messaging around a UVGI Disinfection Program to detail that UVGI can be safe and effective when applied according to a defined and validated protocol 

The messaging program should include the following safety aspects:

*UVGI is a form of actinic radiation which does not cause skin cancer
*UVGI/UVC is not the same as UV found in outdoor sunlight
*UVGI can cause reversible skin and eye irritation
*Skin and eye protection should be worn when the possibility of irradiation is present 
*UV Lamps should not be used for skin or hand sterilisation

The messaging program should include the following efficacy aspects:

*UVGI is a supplemental surface disinfection technology
*UVGI can be used to kill the new coronavirus as well as a number of other common pathogens

==Sampling and Validation==

==Notes and References==
<references />

[[Category: Infection Prevention and Control]]
[[Category: Decontamination]]
[[Category:Crosscutting Issues]]

Directory of Service Providers

2020-06-11T11:33:44Z

Peta: /* Directory of Potential Suppliers and Service Providers */

== '''Directory of Potential Suppliers and Service Providers''' ==
This is a list of potential suppliers and service providers we serendipitously encountered. It is not exhaustive. Inclusion in this list does not mean the CSIR or its affiliated endorses the company. We do not guarantee the suitability and quality of any products or services. Organisations needing to procure services or products should carry out their own investigation to confirm that the relevant company service and products will meet their needs.

The Department of Public Works and Infrastructure (DPWI) and National Treasury, amongst others, are compiling supplier databases.

{| class="wikitable sortable"
|-
! Organisation !! Goods/ services !! Contact person
|-
| '''[https://aecom.com/ AECOM]''' || [[AECOM|Multidisciplinary professional services]] || Adriaan Vorster Architecture Business Line Director
Buildings & Places, Africa, Healthcare Sector Lead, Africa and Middle East D +27-21-950-7531, M +27-82-811-1626 adriaan.vorster@aecom.com
|-
| '''Covid Creative''' || [[Covid Creative|Host sites]] || Asher Marcus Director Hubo Architecture & Design +27 83 570 7348, asher@hubodesign.com
|-
| '''New Horizon Metals''' || [[Portable & freestanding sanitizer and wash basin]] || Sagren Naidoo 0836843760 sagren@nhmetals.co.za
|-
| '''[https://www.transnet.net/Pages/Home.aspx Transnet]''' || [[Miscellaneous heavy engineering and equipment, containerised solutions]] || Riaan Coetzee RCoetzee@csir.co.za
|-
| '''[https://burotech.co.za/ Buro Tech]''' || [[electrical, electronic and mechanical consulting engineers ]] || Santie Pretorius admin@burotech.co.za
|-
| '''[https://dihlase.co.za/ Dihlase]''' || [https://drive.google.com/open?id=1OLN50MRxMOJAlB11LThX8MwaQb3RzsMh Containerised ICU solutions] || Mohamed Rawat capetown@dihlase.co.za
|-
| '''[https://www.franke.com/za/en.html Franke]''' || [[Manufacturing stainless steel hospital equipment]] || Wayne Connor wayne.connor@franke.com
|-
| '''[http://www.siemens.com/ingenuityforlife Siemens]''' || [[Power distribution for hospitals, Rapid deploy HVAC]] || Kruben Bennie Siemens Proprietary Limited RC-ZA SI EP 300 Janadel Avenue Midrand 1685, South Africa Tel.: +27 11 652 7762 Mobile: +27 82 562 9423mailto:kruben.bennie@siemens.com
|-
| '''[https://www.endurocide.com/infection-control/hospital-curtains/ Endurocide Africa]''' || [[Antiseptic impregnated curtains]] || Guy Lombard 082 783 3854, https://www.endurocide.com/infection-control/hospital-curtains/
|-
| '''[http://www.robdyersurgical.co.za/ Rob Dyer Surgical]''' || Sterilization and Disinfection equipment || patrick.dyer@robdyersurgical.co.za
|-
| '''[http://www.aggreko.com/ Aggreko Energy Rental SA]''' || [[Mobile & Modular Power And Temperature Control Solutions]] || Riaan Du Toit on +27 71 473 3013 or riaan.dutoit@aggreko.co.za
|-
|}

[[Category:COVID-19| ]]
[[Category:Service Providers| ]]

The HILLSIDE:Reference desk for COVID-19 Infrastructure/ICU Ventilation for COVID-19

2020-05-20T10:12:55Z

Peta: /* Answer */

== Question: ICU Ventilation for COVID-19? ==
--Question posted anonymously 11:16, 19 May 2020 (SAST) 

"Assuming the virus is a low risk from an aerosolization point of view is it worth investigating the use of HEPA filters to purify the air in the room where we accommodate the COVID-19 patients? The same question can be asked with regards to the use of UV.
Is it not better to try and reduce the virus within the room, rather than filtering the air through a HEPA filter. 

*The existing HVAC places our ICU is under positive pressure. For risk management when housing COVID patients, we wish to convert it to negative pressure. Any advice/ pointers?
*Please provide advice on recirculating air in an ICU, under COVID-19?

"It became clear to me that the spread of COVId-19 is directly connected to the spread of the active virus. Having been Hospital engineer at a 1200 bed local hospital, I am acutely aware that virus longevity depends on, inter alia.:
;#actual time that virus is inside its transmission-carrier fluid,
;#actual temperature during its transmission, and
;#concentration of the virus in carrying fluid (as fluid may evaporate).
Could you consider providing a guideline on these time/temperature characteristics of the virus? 
Only thereafter could architects, engineers etc. identify effective risk-reducing protocols. This could lead to more financially-justifiable 'anti-Corona' measures"

== Discussion ==

These questions are largely unanswerable at the moment but we can try to help by contextualizing what is known, and what a prudent response would be. 
 
SARS-CoV-2 seems to have caused many to rethink their understanding of droplet and airborne transmission. These two transmission mechanisms form a continuum, but the following is is generally accepted:
*''Infectious'' particles <5μm in size can remain suspended and viable for many hours and these contribute to the '''airborne spread'''.
*'''Droplet transmission''' involves larger particles which can also spread through the air for some distance, but the range of transmission is generally considered to be less than 2 meters whereafter particles fall out of the breathing zone. It is important to remember that within this 2 m distance these larger droplets are essentially 'airborne' and diluting ventilation systems have little effect on reducing the risk of droplet transmission. 
Droplet precautions, therefore, include standard precautions like PPE, hand washing and distancing while airborne precautions include negative pressure isolation, respiratory protection, special exhaust or filtration regimes, etc. 

Diseases seldom obey only one mode of transmission (obligatory routes) but often have preferences (preferential routes) while occasionally exploiting circumstances which provide rare opportunities for transmission (opportunistic routes).

SARS-COV-2 is understood to be preferentially droplet and contact spread (a form of droplet spread) with possible rare opportunistic airborne spread, although an extensive outbreak review revealed no indication of airborne spread<ref>https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>. There is still no convincing evidence that it is long-range airborne spread in the sense of droplet nucleation, as with TB<ref>World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) 16-24 February 2020 [Internet]. Geneva: World Health Organization; 2020 Available from: [https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf]</ref>. Where evidence of short-range airborne transmission has been reported this can be seen in the context of short-range droplet spread<ref> Wenzhao Chen, Nan Zhang, Jianjian Wei, Hui-LingYen, and Yuguo Li, “Short-range airborne route dominates exposure of respiratory infection during close contact,” medRxiv preprint, https://doi.org/10.1101/2020.03.16.20037291</ref>. 
Somewhat confusingly, an often reported laboratory study has shown that SARS-CoV-2 can remain viable in air for extended periods<ref name="van Doremalen">Neeltje van Doremalen, Trenton Bushmaker, Dylan H. Morris, Myndi G. Holbrook, Amandine Gamble, Brandi N. Williamson, Azaibi Tamin, Jennifer L. Harcourt, Natalie J. Thornburg, Susan I. Gerber, James O. LloydSmith, Emmie de Wit, and Vincent J. Munster, “Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1,” The New England Journal of Medicine (2020), DOI: 10.1056/NEJMc2004973 [https://www.nejm.org/doi/pdf/10.1056/NEJMc2004973?articleTools=true]</ref>, but no evidence for airborne viability has been found outside of lab settings. Correlations between culture viability, particle size and the real world infectious quantum were not described in this study<ref>https://www.nejm.org/doi/pdf/10.1056/NEJMc2004973?articleTools=true</ref> and I do not think it was the study's intention to claim COVID-19 was airborne. More importantly, similar lab studies have also demonstrated a 3h airborne survival for viral strains not thought to be airborne<ref>Robert Comparison of the Aerosol Stability of 2 Strains of Zaire ebolavirus From the 1976 and 2013 Outbreaks Robert J. Fischer, Trenton Bushmaker, Seth Judson, Vincent J. Munster
J Infect Dis. 2016 Oct 15; 214(Suppl 3): S290–S293. Published online 2016 Oct 4. doi: 10.1093/infdis/jiw193 [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5050463/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5050463/]</ref>. This makes the direct application of these lab studies real-world settings difficult. 

The understanding of the mechanisms of COVID-19 transmission is still largely reliant on what is understood of SARS-CoV-1<ref>Isao Arita, Kazunobu Kojima, and Miyuki Nakane, “Transmission of severe acute respiratory syndrome,” Emerging. Infectious Diseases 9 No. 9 (2003):1183-84, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016764/].</ref> This similarity is reinforced by van Doremalen's survival study<ref name="van Doremalen"/> 
 
The CDC's advice regarding SARS-CoV-1 transmission is still as follows:
''"The primary way that SARS appears to spread is by close person-to-person contact. SARS-CoV is thought to be transmitted most readily by respiratory droplets (droplet spread) produced when an infected person coughs or sneezes. Droplet spread can happen when droplets from the cough or sneeze of an infected person have propelled a short distance (generally up to 3 feet) through the air and deposited on the mucous membranes of the mouth, nose, or eyes of persons who are nearby. SARS-CoV-2 also can spread when a person touches a surface or object contaminated with infectious droplets and then touches his or her mouth, nose, or eye(s). In addition, it is possible that SARS-CoV might be spread more broadly through the air (airborne spread) or by other ways that are not now known."'' - US-CDC <ref>https://www.cdc.gov/sars/about/faq.html</ref>

Studies which have found real-world SARS-CoV-2 in air, ducting and on extraction fans have so far failed to prove that the virus found was still viable<ref>Santarpia et al, “Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center,. medRxiv preprint (2020), [https://doi.org/10.1101/2020.03.23.20039446]</ref><ref>Po Ying Chia et al, 2020 (Preprint) “Detection of Air and Surface Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in Hospital Rooms of Infective Patients,” medRxiv preprint (2020), https://doi.org/10.1101/2020.03.29.20046557 [https://www.medrxiv.org/content/10.1101/2020.03.29.20046557v2.full.pdf]</ref>. It has been suggested that high temperature and humidity would reduce the spread of the virus. The temperature ranges suggested (>50°C) are beyond what anyone could endure in an ICU but the humidity ranges of between 40-60% are achievable. The high humidity slows the nucleation of the viral droplet and increases its settling speed, thereby reducing its range. 

Much of the work being done to understand the transmission mechanism of COVID-19 is focussed on community transmission. It is important to remember that transmission risk in an ICU will not be the same as in homes and workplaces. The conditions and procedures in ICUs could promote transmission<see WHO 2020 below<ref name="WHO 2020">WHO 2020, Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations [https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations]</ref>. Firstly, in a COVID ICU unit, the contamination source strength is much higher than other spaces since infected patients are congregated there. These are presumably ill patients with high viral shedding. Secondly, procedures like intubation are understood to release high quantities of aerosolised particles, unlike with general talking or coughing. Additionally, viral shedding through talking and coughing can be more readily mitigated than from intubation. 
 
The WHO's advice regarding SARS-CoV-2 transmission during clinical interventions is as follows: 
''"In the context of COVID-19, airborne transmission may be possible in specific circumstances and settings in which procedures or support treatments that generate aerosols are performed; i.e., endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, turning the patient to the prone position, disconnecting the patient from the ventilator, non-invasive positive-pressure ventilation, tracheostomy, and cardiopulmonary resuscitation."'' - WHO 2020<ref name="WHO 2020"/> 

--[[User:Tobyvan|Tobyvan]] ([[User talk:Tobyvan|talk]]) 11:16, 19 May 2020 (SAST)

== Answer ==

Without good viability studies of viral particles found in ventilation systems, no firm guidance can be offered regarding the radial rate of viability reduction for SARS-CoV-2 particles. Until that time I think it would be prudent to assume that the virus should be considered as airborne within the confines of an ICU only, based on the guidance of the WHO. This would affect how we treat the filtration and ventilation in a COVID-ICU but I do not believe is sufficient evidence for negative pressurisation of the ICU.

I still believe that air recirculated within an ICU should always be (H13) HEPA filtered for reasons beyond just COVID. Therefore, assuming systems are designed in accordance with the IUSS BES guide, there should be no reason to change their configuration or pressurisation. Risk assessments should be conducted for ICUs immediately adjacent to public waiting areas or other high traffic areas, with corrective actions including reducing occupancy times and rates for these areas.

In all likelihood, we will be able to look back and say we overreacted in the name of patient and worker safety, but we should be wary of being criticised by retrospective experts of not having had the best interests of our staff and patients at heart.

--[[User:Tobyvan|Tobyvan]] ([[User talk:Tobyvan|talk]]) 11:16, 19 May 2020 (SAST)
----

== Notes and References ==
[[Category:Reference Desk]]
[[Category:COVID-19]]
[[Category:ICU]]
[[Category:Airbone Infection control]]

The HILLSIDE:Reference desk for COVID-19 Infrastructure/ICU Ventilation for COVID-19

2020-05-20T10:08:35Z

Peta: /* Discussion */

== Question: ICU Ventilation for COVID-19? ==
--Question posted anonymously 11:16, 19 May 2020 (SAST) 

"Assuming the virus is a low risk from an aerosolization point of view is it worth investigating the use of HEPA filters to purify the air in the room where we accommodate the COVID-19 patients? The same question can be asked with regards to the use of UV.
Is it not better to try and reduce the virus within the room, rather than filtering the air through a HEPA filter. 

*The existing HVAC places our ICU is under positive pressure. For risk management when housing COVID patients, we wish to convert it to negative pressure. Any advice/ pointers?
*Please provide advice on recirculating air in an ICU, under COVID-19?

"It became clear to me that the spread of COVId-19 is directly connected to the spread of the active virus. Having been Hospital engineer at a 1200 bed local hospital, I am acutely aware that virus longevity depends on, inter alia.:
;#actual time that virus is inside its transmission-carrier fluid,
;#actual temperature during its transmission, and
;#concentration of the virus in carrying fluid (as fluid may evaporate).
Could you consider providing a guideline on these time/temperature characteristics of the virus? 
Only thereafter could architects, engineers etc. identify effective risk-reducing protocols. This could lead to more financially-justifiable 'anti-Corona' measures"

== Discussion ==

These questions are largely unanswerable at the moment but we can try to help by contextualizing what is known, and what a prudent response would be. 
 
SARS-CoV-2 seems to have caused many to rethink their understanding of droplet and airborne transmission. These two transmission mechanisms form a continuum, but the following is is generally accepted:
*''Infectious'' particles <5μm in size can remain suspended and viable for many hours and these contribute to the '''airborne spread'''.
*'''Droplet transmission''' involves larger particles which can also spread through the air for some distance, but the range of transmission is generally considered to be less than 2 meters whereafter particles fall out of the breathing zone. It is important to remember that within this 2 m distance these larger droplets are essentially 'airborne' and diluting ventilation systems have little effect on reducing the risk of droplet transmission. 
Droplet precautions, therefore, include standard precautions like PPE, hand washing and distancing while airborne precautions include negative pressure isolation, respiratory protection, special exhaust or filtration regimes, etc. 

Diseases seldom obey only one mode of transmission (obligatory routes) but often have preferences (preferential routes) while occasionally exploiting circumstances which provide rare opportunities for transmission (opportunistic routes).

SARS-COV-2 is understood to be preferentially droplet and contact spread (a form of droplet spread) with possible rare opportunistic airborne spread, although an extensive outbreak review revealed no indication of airborne spread<ref>https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>. There is still no convincing evidence that it is long-range airborne spread in the sense of droplet nucleation, as with TB<ref>World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) 16-24 February 2020 [Internet]. Geneva: World Health Organization; 2020 Available from: [https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf]</ref>. Where evidence of short-range airborne transmission has been reported this can be seen in the context of short-range droplet spread<ref> Wenzhao Chen, Nan Zhang, Jianjian Wei, Hui-LingYen, and Yuguo Li, “Short-range airborne route dominates exposure of respiratory infection during close contact,” medRxiv preprint, https://doi.org/10.1101/2020.03.16.20037291</ref>. 
Somewhat confusingly, an often reported laboratory study has shown that SARS-CoV-2 can remain viable in air for extended periods<ref name="van Doremalen">Neeltje van Doremalen, Trenton Bushmaker, Dylan H. Morris, Myndi G. Holbrook, Amandine Gamble, Brandi N. Williamson, Azaibi Tamin, Jennifer L. Harcourt, Natalie J. Thornburg, Susan I. Gerber, James O. LloydSmith, Emmie de Wit, and Vincent J. Munster, “Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1,” The New England Journal of Medicine (2020), DOI: 10.1056/NEJMc2004973 [https://www.nejm.org/doi/pdf/10.1056/NEJMc2004973?articleTools=true]</ref>, but no evidence for airborne viability has been found outside of lab settings. Correlations between culture viability, particle size and the real world infectious quantum were not described in this study<ref>https://www.nejm.org/doi/pdf/10.1056/NEJMc2004973?articleTools=true</ref> and I do not think it was the study's intention to claim COVID-19 was airborne. More importantly, similar lab studies have also demonstrated a 3h airborne survival for viral strains not thought to be airborne<ref>Robert Comparison of the Aerosol Stability of 2 Strains of Zaire ebolavirus From the 1976 and 2013 Outbreaks Robert J. Fischer, Trenton Bushmaker, Seth Judson, Vincent J. Munster
J Infect Dis. 2016 Oct 15; 214(Suppl 3): S290–S293. Published online 2016 Oct 4. doi: 10.1093/infdis/jiw193 [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5050463/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5050463/]</ref>. This makes the direct application of these lab studies real-world settings difficult. 

The understanding of the mechanisms of COVID-19 transmission is still largely reliant on what is understood of SARS-CoV-1<ref>Isao Arita, Kazunobu Kojima, and Miyuki Nakane, “Transmission of severe acute respiratory syndrome,” Emerging. Infectious Diseases 9 No. 9 (2003):1183-84, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016764/].</ref> This similarity is reinforced by van Doremalen's survival study<ref name="van Doremalen"/> 
 
The CDC's advice regarding SARS-CoV-1 transmission is still as follows:
''"The primary way that SARS appears to spread is by close person-to-person contact. SARS-CoV is thought to be transmitted most readily by respiratory droplets (droplet spread) produced when an infected person coughs or sneezes. Droplet spread can happen when droplets from the cough or sneeze of an infected person have propelled a short distance (generally up to 3 feet) through the air and deposited on the mucous membranes of the mouth, nose, or eyes of persons who are nearby. SARS-CoV-2 also can spread when a person touches a surface or object contaminated with infectious droplets and then touches his or her mouth, nose, or eye(s). In addition, it is possible that SARS-CoV might be spread more broadly through the air (airborne spread) or by other ways that are not now known."'' - US-CDC <ref>https://www.cdc.gov/sars/about/faq.html</ref>

Studies which have found real-world SARS-CoV-2 in air, ducting and on extraction fans have so far failed to prove that the virus found was still viable<ref>Santarpia et al, “Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center,. medRxiv preprint (2020), [https://doi.org/10.1101/2020.03.23.20039446]</ref><ref>Po Ying Chia et al, 2020 (Preprint) “Detection of Air and Surface Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in Hospital Rooms of Infective Patients,” medRxiv preprint (2020), https://doi.org/10.1101/2020.03.29.20046557 [https://www.medrxiv.org/content/10.1101/2020.03.29.20046557v2.full.pdf]</ref>. It has been suggested that high temperature and humidity would reduce the spread of the virus. The temperature ranges suggested (>50°C) are beyond what anyone could endure in an ICU but the humidity ranges of between 40-60% are achievable. The high humidity slows the nucleation of the viral droplet and increases its settling speed, thereby reducing its range. 

Much of the work being done to understand the transmission mechanism of COVID-19 is focussed on community transmission. It is important to remember that transmission risk in an ICU will not be the same as in homes and workplaces. The conditions and procedures in ICUs could promote transmission<see WHO 2020 below<ref name="WHO 2020">WHO 2020, Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations [https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations]</ref>. Firstly, in a COVID ICU unit, the contamination source strength is much higher than other spaces since infected patients are congregated there. These are presumably ill patients with high viral shedding. Secondly, procedures like intubation are understood to release high quantities of aerosolised particles, unlike with general talking or coughing. Additionally, viral shedding through talking and coughing can be more readily mitigated than from intubation. 
 
The WHO's advice regarding SARS-CoV-2 transmission during clinical interventions is as follows: 
''"In the context of COVID-19, airborne transmission may be possible in specific circumstances and settings in which procedures or support treatments that generate aerosols are performed; i.e., endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, turning the patient to the prone position, disconnecting the patient from the ventilator, non-invasive positive-pressure ventilation, tracheostomy, and cardiopulmonary resuscitation."'' - WHO 2020<ref name="WHO 2020"/> 

--[[User:Tobyvan|Tobyvan]] ([[User talk:Tobyvan|talk]]) 11:16, 19 May 2020 (SAST)

== Answer ==

Without good viability studies of viral particles found in ventilation systems, no firm guidance can be offered regarding the radial rate of viability reduction for SARS-CoV-2 particles. Until that time I think it would be prudent to assume that the virus should be considered as airborne within the confines of an ICU only, based on the guidance of the WHO. This would affect how we treat the filtration and ventilation in a COVID-ICU but I do not believe is sufficient evidence for negative pressurisation of the ICU.

I still believe that air recirculated within an ICU should always be (H13) HEPA filtered for reasons beyond just COVID. Therefore, assuming systems are designed in accordance with the IUSS BES guide, There should be no reason to change their configuration or pressurisation. Risk assessments should be conducted for ICUs immediately adjacent to public waiting areas or other high traffic areas, with corrective actions including reducing occupancy times and rates for these areas.

In all likelihood, we will be able to look back and say we overreacted in the name of patient and worker safety, but we should be wary of being criticised by retrospective experts of not having had the best interests of our staff and patients at heart.

--[[User:Tobyvan|Tobyvan]] ([[User talk:Tobyvan|talk]]) 11:16, 19 May 2020 (SAST)
----

== Notes and References ==
[[Category:Reference Desk]]
[[Category:COVID-19]]
[[Category:ICU]]
[[Category:Airbone Infection control]]

User:JGibberd

2020-05-19T09:07:51Z

Peta:

Architect and Researcher at the CSIR.

The HILLSIDE:Reference desk for COVID-19 Infrastructure

2020-05-19T07:31:29Z

Peta:

If the virus is a low risk from an aerosolization point of view is it worth investigating the use of HEPA filters to purify the air in room where we accommodate the Covid patients. The same question can be asked with regards to the use of UV.

However my opinion is that you may have a better chance of reducing the virus within the room than filtering the air through a HEPA filter.

The existing HVAC places our ICU is under positive pressure. For risk management when housing Covid patients, we wish to convert it to negative pressure. Any advice/ pointers?

Please provide advice on recirculating air in an ICU, under Covid?

It became clear to me that the spread of Corona is directly connected to the spread of active virus. Having been Hospital engineer at a 1200 bed local hospital, I am acutely aware that virus longevity depends on, i.a.: a) actual time that virus is inside its transmission-carrier fluid, b) actual temperature during its transmission, and c) concentration of virus in carrying fluid(as fluid may evaporate).
Could you consider providing a guideline on these time/temperature characteristics of the virus.? Only thereafter could architects, engineers etc. identify effective risk-reducing protocols. This could lead to more financially-justifiable 'anti-Corona' measures.

The HILLSIDE:Reference desk for COVID-19 Infrastructure

2020-05-19T06:21:50Z

Peta:

Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control

2020-05-18T14:28:20Z

Peta: /* Ultraviolet Surface Disinfection for SARS-CoV-2 */

*[[Infrastructure Guidance for COVID-19|Infrastructure Guidance for COVID-19]]
*[[Infrastructure Guidance for COVID-19/Alternate_Care_Sites#Infection_Prevention_and_Control|Alternate Care Sites]]
*[[Infection Prevention and Control/Surface Decontamination|Surface Decontamination]]
*[[Infection Prevention and Control/Air Disinfection|Air Disinfection]]
 
== Infection prevention and control for COVID-19 ==
Infection prevention and control in the context of Covid-19 should focus on three pillars: exposure reduction by workflow, cleaning disinfection and decontamination, and use of personal protective equipment.
=== General Concern: ===
==== ''Contact and droplet spread'' ====
Transmission of SARS-CoV-2 virus occurs via contact and droplet spread. The virus has been shown to persist on surfaces for extended periods of time and is known to be efficient at infecting people.
Waste products: As SARS-CoV-02 is carried in body fluids and fecal matter, disposal of contaminated items (tissues) and cleaning regimes (spaces, garments, linen) should be accommodated carefully in the workflow design and infrastructure provision.

=== Limited Concern:===
==== ''Water and Sewerage Contamination'' ====
The International Water Association (Link to Report) concluded that water and sewerage contamination is not considered to be a key risk factor for Covid-19. The panel expressed concern for how waste and specifically wastewater (medical) would be handled by places (e.g., hostels, hotels) that are used to serve as interim Covid-19 quarantine or testing facilities or accommodation. These are places other than hospitals that are used in the interim for such purposes and do not usually handle medical wastewater. Such facilities should be monitored carefully.
==== ''Airborne Transmission'' ====
Under exceptional circumstances, where the risk of airborne transmission arises the following should be considered.
Where aerosolising activities have a potential of contaminating occupied spaces with partially diluted or undiluted contaminated air, or where this is indeterminate, aerosolising activities should be designated to an alternate area. In the event that an alternative is not available, some treatment regime (air filtration or air disinfection) may be necessary.

As SARS-CoV-2 is not considered airborne, general respiratory protection against airborne transmission is not considered necessary, except where aerosolisation of particles may be likely. The following procedures have been identified as having the potential for liberating infectious aerosols. 
*tracheal intubation,
*non-invasive ventilation,
*tracheotomy,
*cardiopulmonary resuscitation,
*manual ventilation before intubation and bronchoscopy
*diagnostic sampling as patients can be induced to cough and sneeze

== Administrative controls ==
=== Site Layout ===
ACS will accommodate a variety of clinical, logistical, support and auxiliary services associated with the render of care. Functions to be accommodated are:
==== Clinical services ====
Triage, rapid assessment of persons entering the facility, to expeditiously identify and render the appropriate service.
Inpatient accommodation organised according to cohorting principles, discussed below.
Testing and diagnostics, including laboratories and x-ray.
==== Pharmacy ====

==== Logistical ====
Staff entry, preparations to transition from outside to clinical work environment, including pause areas for relief.
Emergency services, visitors
Goods, supplies and storage
Waste removal

==== Support services ====
Support services key to the provision of clinical services should be separated, so that the risks and associated with that particular activity can be managed. Support services are:
*Kitchen
*Laundry
*Mortuary
Support services can be provided off-site, in which case safe, secure and efficient transfer and logistical arrangements should be designed.

Auxiliary services may be provided on or near the ACS site. This included overnight accommodation for staff who may not wish to return home to avoid exposing their families, or who need rest between shifts, or for discharged patients awaiting transport home, volunteers who have recovered from SARS-CoV-2.
Limited psychosocial services and allied health services may also be provided on or near ACS for example by approved NGOs.

Spatial configuration and layout can ensure unnecessary cross-over of function is avoided. This entails systematic separation of functions and managed transition between activities to facilitate consistency of care, an orderly, efficient work environment, less waste and reduced risk for improved outcomes. To achieve this, functional relationships should first be considered at the site level before being considered at the unit level.

== Personal Protective Equipment ==
=== Respiratory Protective Equipment ===
Filtering facepiece respirators (FFR), are subject to various regulatory standards around the world<ref>https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/faqs-shortages-surgical-masks-and-gowns-during-covid-19-pandemic</ref>. These standards specify certain required physical properties and performance characteristics in order for respirators to claim compliance with the particular standard. During pandemic or emergency situations, health authorities often reference these standards when making respirator recommendations. N95 masks alone and FFP2s with fluid shields are recommended for use by healthcare workers operating in high-risk COVID-19 settings. FFP2 and N95 masks filter at least 94% of a challenge aerosol with a mean mass diameter of between 0.3 and 0.4 microns. This filtration range includes the new coronavirus. 

:; Emergency use recommendations
:Hospitals across South Africa are running out of N95 respirators are tested and certified by the National Institute for Occupational Safety and Health, or NIOSH, a research agency that is part of the Centers for Disease Control and Prevention (CDC). In response to continued respirator shortages, the U.S Food and Drug Administration (FDA) issued an emergency use authorization for KN95 masks<ref>https://www.fda.gov/media/136663/download</ref>. Regulated by the Chinese government, these are almost identical in performance to N95 masks. There are slight differences in their specifications, like a variation in the maximum pressure the masks must be able to withstand as a person inhales and exhales<ref>https://multimedia.3m.com/mws/media/1791500O/comparison-ffp2-kn95-n95-filtering-facepiece-respirator-classes-tb.pdf</ref>. In South Africa, FFRs are promulgated under South African National Standard [https://store.sabs.co.za/catalog/product/view/_ignore_category/1/id/2136527/s/sans-1866-2-ed-1-00-1 SANS 1866-2] and regulated under the compulsory specification VC8072. While in South Africa KN95 respirators were already in use since the Covid-19 outbreak, there were no specific guidelines on which criteria to be met in order to use the product, including evidence demonstrating that the respirator is authentic. In addition, there is conflicting guidance over the application of these respiratory masks.

:N95 and FFP2 respirators have been considered the preferred type of respirators in South African healthcare settings. These respirators are a crucial piece of equipment for healthcare workers treating coronavirus-infected patients in some countries. In response to the limited supply of N95 respirators, KN95 arose as an alternative. However, there are many questions about the quality and effectiveness of the similarly named KN95 respirators which originates from China. In its current guidance, the SANS 1866 pt. 2 has set out a specification that the N95 and FFP range of respirators should meet. 
:Before adopting the use of KN95s in South Africa, there is an urgent need to address the challenges in determining the authenticity of KN95 that are currently being used in SA settings in order to avoid fraudulent products being identified as KN95s making their way into healthcare settings. Until those challenges are addressed, KN95s should be used with extreme prejudice.

*While respirators equivalent to FFP2/N95 are not available, the use of surgical masks with visors is an acceptable interim alternative to FFR

==Environmental Controls==
===Ultraviolet Surface Disinfection for SARS-CoV-2 ===
UV-C air disinfection was been explored extensively in the context of TB infection prevention and control by the South African scientific community in association with international experts. National Technical Standards, Protocols, [[Infection Prevention and Control/Air Disinfection#Implementation of Upper Room UVGI|guidelines]] and testing capacity for application of upper-room UVGI in airborne transmission have been established<ref>https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged</ref>. This experience has provided important basic knowledge and key insights into the underpinning science and theory as well as application constraints, albeit for a different application. 

The coronavirus, [http://SARSs-CoV-2|https://en.wikipedia.org/wiki/Severe_acute_respiratory_syndrome_coronavirus_2 SARSs-CoV-2], is understood to be transmitted primarily by contact and droplet spread<ref> WHO 2020 Modes of transmission of the virus causing COVID-19: implications for IPC precaution recommendations [https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-COVID-19-implications-for-ipc-precaution-recommendations https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-COVID-19-implications-for-ipc-precaution-recommendations]</ref>, is highly contagious and spreads more rapidly than its predecessors Severe Acute Respiratory Syndrome (SARS-Cov-1) and Middle East Respiratory Syndrome (MERS)</ref><ref name="cite">Citation Needed</ref>, so any residual surface contamination can pose a public health threat<ref name="cite"/>. COVID-19 transmission remains controversial as researchers across the globe remain conflicted about droplet and airborne as modes of transmission<ref name="cite"/>.
Clarifying the transmission routes and survival of viruses on frequently used surfaces is essential for containment of the outbreak. Research has successfully demonstrated that the virus has the potential to be aerosolised<ref name="van Doremalen 2020">van Doremalen, N, Bushmaker, T, and Morris, DH e.tal Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. New England Journal of Medicine. March 17, 2020 [https://www.nejm.org/doi/full/10.1056/NEJMc2004973]</ref>, and therefore can theoretically opportunistically transmit through the airborne route, it is understood that, except in aerosolising procedures, risk of coronavirus transmission via the airborne route <ref name="Lindsley 2018">Lindsley, W.G, McLelland, T.L. and Neu, D.T. et. al. 2018. Ambulance Disinfection using Ultraviolet Germicidal Irradiation (UVGI): Effects of Fixture Location and Surface Reflectivity. [https://www.ncbi.nlm.nih.gov/pubmed/29059039]</ref> is low.
Similarly, risk via water and wastewater is low <ref>Steyn, M. (2020, April 8). Summary notes of the International Water Association (IWA) Webinar: “Covid-19: A Water Professional’s Perspective”. [[Infrastructure Guidance for COVID-19/Alternate Care Sites/COVID-19 A Water Professionals Perspective]]</ref>. Persistence of the virus on a variety of surfaces has been demonstrated <ref name="van Doremalen 2020"/>, underpinning concern that SARS-CoV-2 may be transmitted from infected (even asymptomatic) persons to others from touching common surfaces, even after the infector has departed for several hours <ref>Cai et al, 2020, Indirect Virus Transmission in Cluster of COVID-19 Cases, Wenzhou, China, 2020, Emerging Infectious Diseases, 2020, [https://wwwnc.cdc.gov/eid/article/26/6/20-0412_article https://wwwnc.cdc.gov/eid/article/26/6/20-0412_article]</ref><ref>Le et al, 2020, Asymptomatic and Human-to-Human Transmission of SARS-CoV-2 in a 2-Family Cluster, Xuzhou, China, Emerging Infectious Diseases, 2020, [https://wwwnc.cdc.gov/eid/article/26/7/20-0718_article https://wwwnc.cdc.gov/eid/article/26/7/20-0718_article]</ref>. Efforts to contain the coronavirus, to stem the pandemic, should therefore primarily focus on contact and droplet transmission.
Contact and droplet transmission is of concern in public transport systems taxis which convey very large transient populations is normally congested conditions, such as in trains and mini-bus taxis. Transfer of suspected or confirmed Covid-19 patients in planned transport or emergency service vehicles poses a risk since studies show that conventional decontamination procedures may be inadequat<ref name="Lindsley 2018"/>. In a pandemic, and within already constrained congregate settings found in infrastructure such as clinics, hospitals, prisons, schools and transport hubs, overcrowding and close proximity of infectious and susceptible individuals could create conditions which amplify the risk of Covid-19 transmission. 

In the South African context, the reduction of exposure to Covid-19 is a priority, in order to:
*reduce and delay occupational exposure of frontline workers especially healthcare and transport services workers;
*reduce exposure to public health risk, especially to the most vulnerable, such as PLHIV and persons with TB who are the principal users of public transport;
*contribute to the strategy of “flattening the curve”; and
*preserve and protect the healthcare service so as to ensure continued service.

This article proposes UV-C surface disinfection for reducing contact and droplet transmission of SARS-CoV-2 through the following applications:
#Portable disinfection devices for use in the transport sector (minibus taxis, trains and emergency and planned patient transport)
#Public Spaces
#Commercial and industrial occupational settings
#Decontamination of personal and respiratory protection equipment

== Notes and References ==
<references/>

----

Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control

2020-05-18T14:26:58Z

Peta: /* Ultraviolet Surface Disinfection for SARS-CoV-2 */

*[[Infrastructure Guidance for COVID-19|Infrastructure Guidance for COVID-19]]
*[[Infrastructure Guidance for COVID-19/Alternate_Care_Sites#Infection_Prevention_and_Control|Alternate Care Sites]]
*[[Infection Prevention and Control/Surface Decontamination|Surface Decontamination]]
*[[Infection Prevention and Control/Air Disinfection|Air Disinfection]]
 
== Infection prevention and control for COVID-19 ==
Infection prevention and control in the context of Covid-19 should focus on three pillars: exposure reduction by workflow, cleaning disinfection and decontamination, and use of personal protective equipment.
=== General Concern: ===
==== ''Contact and droplet spread'' ====
Transmission of SARS-CoV-2 virus occurs via contact and droplet spread. The virus has been shown to persist on surfaces for extended periods of time and is known to be efficient at infecting people.
Waste products: As SARS-CoV-02 is carried in body fluids and fecal matter, disposal of contaminated items (tissues) and cleaning regimes (spaces, garments, linen) should be accommodated carefully in the workflow design and infrastructure provision.

=== Limited Concern:===
==== ''Water and Sewerage Contamination'' ====
The International Water Association (Link to Report) concluded that water and sewerage contamination is not considered to be a key risk factor for Covid-19. The panel expressed concern for how waste and specifically wastewater (medical) would be handled by places (e.g., hostels, hotels) that are used to serve as interim Covid-19 quarantine or testing facilities or accommodation. These are places other than hospitals that are used in the interim for such purposes and do not usually handle medical wastewater. Such facilities should be monitored carefully.
==== ''Airborne Transmission'' ====
Under exceptional circumstances, where the risk of airborne transmission arises the following should be considered.
Where aerosolising activities have a potential of contaminating occupied spaces with partially diluted or undiluted contaminated air, or where this is indeterminate, aerosolising activities should be designated to an alternate area. In the event that an alternative is not available, some treatment regime (air filtration or air disinfection) may be necessary.

As SARS-CoV-2 is not considered airborne, general respiratory protection against airborne transmission is not considered necessary, except where aerosolisation of particles may be likely. The following procedures have been identified as having the potential for liberating infectious aerosols. 
*tracheal intubation,
*non-invasive ventilation,
*tracheotomy,
*cardiopulmonary resuscitation,
*manual ventilation before intubation and bronchoscopy
*diagnostic sampling as patients can be induced to cough and sneeze

== Administrative controls ==
=== Site Layout ===
ACS will accommodate a variety of clinical, logistical, support and auxiliary services associated with the render of care. Functions to be accommodated are:
==== Clinical services ====
Triage, rapid assessment of persons entering the facility, to expeditiously identify and render the appropriate service.
Inpatient accommodation organised according to cohorting principles, discussed below.
Testing and diagnostics, including laboratories and x-ray.
==== Pharmacy ====

==== Logistical ====
Staff entry, preparations to transition from outside to clinical work environment, including pause areas for relief.
Emergency services, visitors
Goods, supplies and storage
Waste removal

==== Support services ====
Support services key to the provision of clinical services should be separated, so that the risks and associated with that particular activity can be managed. Support services are:
*Kitchen
*Laundry
*Mortuary
Support services can be provided off-site, in which case safe, secure and efficient transfer and logistical arrangements should be designed.

Auxiliary services may be provided on or near the ACS site. This included overnight accommodation for staff who may not wish to return home to avoid exposing their families, or who need rest between shifts, or for discharged patients awaiting transport home, volunteers who have recovered from SARS-CoV-2.
Limited psychosocial services and allied health services may also be provided on or near ACS for example by approved NGOs.

Spatial configuration and layout can ensure unnecessary cross-over of function is avoided. This entails systematic separation of functions and managed transition between activities to facilitate consistency of care, an orderly, efficient work environment, less waste and reduced risk for improved outcomes. To achieve this, functional relationships should first be considered at the site level before being considered at the unit level.

== Personal Protective Equipment ==
=== Respiratory Protective Equipment ===
Filtering facepiece respirators (FFR), are subject to various regulatory standards around the world<ref>https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/faqs-shortages-surgical-masks-and-gowns-during-covid-19-pandemic</ref>. These standards specify certain required physical properties and performance characteristics in order for respirators to claim compliance with the particular standard. During pandemic or emergency situations, health authorities often reference these standards when making respirator recommendations. N95 masks alone and FFP2s with fluid shields are recommended for use by healthcare workers operating in high-risk COVID-19 settings. FFP2 and N95 masks filter at least 94% of a challenge aerosol with a mean mass diameter of between 0.3 and 0.4 microns. This filtration range includes the new coronavirus. 

:; Emergency use recommendations
:Hospitals across South Africa are running out of N95 respirators are tested and certified by the National Institute for Occupational Safety and Health, or NIOSH, a research agency that is part of the Centers for Disease Control and Prevention (CDC). In response to continued respirator shortages, the U.S Food and Drug Administration (FDA) issued an emergency use authorization for KN95 masks<ref>https://www.fda.gov/media/136663/download</ref>. Regulated by the Chinese government, these are almost identical in performance to N95 masks. There are slight differences in their specifications, like a variation in the maximum pressure the masks must be able to withstand as a person inhales and exhales<ref>https://multimedia.3m.com/mws/media/1791500O/comparison-ffp2-kn95-n95-filtering-facepiece-respirator-classes-tb.pdf</ref>. In South Africa, FFRs are promulgated under South African National Standard [https://store.sabs.co.za/catalog/product/view/_ignore_category/1/id/2136527/s/sans-1866-2-ed-1-00-1 SANS 1866-2] and regulated under the compulsory specification VC8072. While in South Africa KN95 respirators were already in use since the Covid-19 outbreak, there were no specific guidelines on which criteria to be met in order to use the product, including evidence demonstrating that the respirator is authentic. In addition, there is conflicting guidance over the application of these respiratory masks.

:N95 and FFP2 respirators have been considered the preferred type of respirators in South African healthcare settings. These respirators are a crucial piece of equipment for healthcare workers treating coronavirus-infected patients in some countries. In response to the limited supply of N95 respirators, KN95 arose as an alternative. However, there are many questions about the quality and effectiveness of the similarly named KN95 respirators which originates from China. In its current guidance, the SANS 1866 pt. 2 has set out a specification that the N95 and FFP range of respirators should meet. 
:Before adopting the use of KN95s in South Africa, there is an urgent need to address the challenges in determining the authenticity of KN95 that are currently being used in SA settings in order to avoid fraudulent products being identified as KN95s making their way into healthcare settings. Until those challenges are addressed, KN95s should be used with extreme prejudice.

*While respirators equivalent to FFP2/N95 are not available, the use of surgical masks with visors is an acceptable interim alternative to FFR

==Environmental Controls==
===Ultraviolet Surface Disinfection for SARS-CoV-2 ===
UV-C air disinfection was been explored extensively in the context of TB infection prevention and control by the South African scientific community in association with international experts. National Technical Standards, Protocols, [[Infection Prevention and Control/Air Disinfection#Implementation of Upper Room UVGI|guidelines]] and testing capacity for application of upper-room UVGI in airborne transmission have been established<ref>https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged</ref>. This experience has provided important basic knowledge and key insights into the underpinning science and theory as well as application constraints, albeit for a different application. 

The coronavirus, [http://SARSs-CoV-2|https://en.wikipedia.org/wiki/Severe_acute_respiratory_syndrome_coronavirus_2 SARSs-CoV-2], is understood to be transmitted primarily by contact and droplet spread<ref> WHO 2020 Modes of transmission of the virus causing COVID-19: implications for IPC precaution recommendations [https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-COVID-19-implications-for-ipc-precaution-recommendations https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-COVID-19-implications-for-ipc-precaution-recommendations]</ref>, is highly contagious and spreads more rapidly than its predecessors Severe Acute Respiratory Syndrome (SARS-Cov-1) and Middle East Respiratory Syndrome (MERS)</ref><ref name="cite">Citation Needed</ref>, so any residual surface contamination can pose a public health threat<ref name="cite"/>. COVID-19 transmission remains controversial as researchers across the globe remain conflicted about droplet and airborne as modes of transmission<ref name="cite"/>.
Clarifying the transmission routes and survival of viruses on frequently used surfaces is essential for containment of the outbreak. Research has successfully demonstrated that the virus has the potential to be aerosolised<ref name="van Doremalen 2020">van Doremalen, N, Bushmaker, T, and Morris, DH e.tal Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. New England Journal of Medicine. March 17, 2020 [https://www.nejm.org/doi/full/10.1056/NEJMc2004973]</ref>, and therefore can theoretically opportunistically transmit through the airborne route, it is understood that, except in aerosolising procedures, risk of coronavirus transmission via the airborne route <ref name="Lindsley 2018">Lindsley, W.G, McLelland, T.L. and Neu, D.T. et. al. 2018. Ambulance Disinfection using Ultraviolet Germicidal Irradiation (UVGI): Effects of Fixture Location and Surface Reflectivity. [https://www.ncbi.nlm.nih.gov/pubmed/29059039]</ref> is low.
Similarly, risk via water and wastewater is low <ref>Steyn, M. (2020, April 8). Summary notes of the International Water Association (IWA) Webinar: “Covid-19: A Water Professional’s Perspective”. [[Infrastructure Guidance for COVID-19/Alternate Care Sites/COVID-19 A Water Professionals Perspective]]</ref>. Persistence of the virus on a variety of surfaces has been demonstrated <ref name="van Doremalen 2020"/>, underpinning concern that SARS-CoV-2 may be transmitted from infected (even asymptomatic) persons to others from touching common surfaces, even after the infector has departed for several hours <ref>Cai et al, 2020, Indirect Virus Transmission in Cluster of COVID-19 Cases, Wenzhou, China, 2020, Emerging Infectious Diseases, 2020, [https://wwwnc.cdc.gov/eid/article/26/6/20-0412_article https://wwwnc.cdc.gov/eid/article/26/6/20-0412_article]</ref><ref>Le et al, 2020, Asymptomatic and Human-to-Human Transmission of SARS-CoV-2 in a 2-Family Cluster, Xuzhou, China, Emerging Infectious Diseases, 2020, [https://wwwnc.cdc.gov/eid/article/26/7/20-0718_article https://wwwnc.cdc.gov/eid/article/26/7/20-0718_article]</ref>. Efforts to contain the coronavirus, to stem the pandemic, should therefore primarily focus on contact and droplet transmission.
Contact and droplet transmission is of concern in public transport systems taxis which convey very large transient populations is normally congested conditions, such as in trains and mini-bus taxis. Transfer of suspected or confirmed Covid-19 patients in planned transport or emergency service vehicles poses a risk since studies show that conventional decontamination procedures may be inadequat<ref name="Lindsley 2018"/>. In a pandemic, and within already constrained healthcare infrastructure, overcrowding and close proximity of infectious and susceptible individuals could create conditions which amplify the risk of Covid-19 transmission. 

In the South African context, the reduction of exposure to Covid-19 is a priority, in order to:
*reduce and delay occupational exposure of frontline workers especially healthcare and transport services workers;
*reduce exposure to public health risk, especially to the most vulnerable, such as PLHIV and persons with TB who are the principal users of public transport;
*contribute to the strategy of “flattening the curve”; and
*preserve and protect the healthcare service so as to ensure continued service.

This article proposes UV-C surface disinfection for reducing contact and droplet transmission of SARS-CoV-2 through the following applications:
#Portable disinfection devices for use in the transport sector (minibus taxis, trains and emergency and planned patient transport)
#Public Spaces
#Commercial and industrial occupational settings
#Decontamination of personal and respiratory protection equipment

== Notes and References ==
<references/>

----

Infrastructure Guidance for COVID-19/Alternate Care Sites

2020-05-18T09:38:18Z

Peta: /* Exclusions */

[[Infrastructure Guidance for COVID-19|Return to Infrastructure Guidance for COVID-19]] 

== '''Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19'''==

This guidance work was initiated under the project titled: 
''Reducing Nosocomial and Community-Acquired Tuberculosis by Strengthening the Capacity of the South African Department of Health to Improve Implementation of Infection Control and Waste Management at All Levels of the Health System Under the President's Emergency Plan for AIDS Relief (PEPFAR)'' 

== '''Introduction''' ==
=== Purpose and approach ===
The global pandemic of COVID-19 caused by the coronavirus, SARS-CoV-2 is likely to result in a surge in need for medical care for Severe Acute Respiratory Syndrome (SARS) in South Africa. Considering the course of the pandemic in other countries, it is anticipated that South African hospitals will not have sufficient capacity to cope with the surge of persons requiring medical attention and that surge capacity via alternate care sites (ACS) will need to be established.
Surge capacity, contemplated here is not the frequent emergency department overcrowding experienced by healthcare facilities (e.g. Friday/Saturday night emergencies) or local casualty emergency that might overcrowd nearby facilities and have little to no impact on the overall healthcare delivery system. It is when a catastrophic event occurs and the affected population seek medical care from existing local healthcare facilities, causing healthcare infrastructure to become exhausted due to excess in demand. During a healthcare surge, the standard of care will shift from focusing on patient-based outcomes to population-based outcomes, and providers should anticipate “a shift to providing care and allocating scarce equipment, supplies and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals.”<ref>[https://asprtracie.hhs.gov/technical-resources/resource/491/altered-standards-of-care-in-mass-casualty-events Health Systems Research Inc., 2005]</ref> 

Surge capacity can be temporarily established in non-traditional environments, such as hotels, exhibition halls, community halls, and as field hospitals, on open spaces. 

In the context of this document, a quarantine site is a facility for patients who do not require continuous professional medical care, while an ACS is defined as a temporary facility that can provide continuous medical care for SARS. This document provides principles and considerations, high-level guidance for minimum requirements and examples for ACS. 

While an extensive set of health facility guidelines does exist<ref>[https://www.iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-servi IUSS Building Engineering Services (2017)]</ref>, these are applicable for conventional facilities and thus include services and guidelines that are not necessarily relevant to the treatment of a novel, highly infectious pathogen, with pandemic effects. Moreover, these do not provide well for the rapid and temporary establishment of facilities. 

In order to formulate high-level guidance, [[as invited by Business for South Africa]], the team reached out to professional industry bodies for inputs, in particular the South African Institute for Architects (SAIA), The Gauteng Institute for Architects (GiFA) [https://www.gifa.org.za/ Gauteng Institute for Architecture] and the [http://www.safhe.co.za/ South African Federation of Hospital Engineering (SAFHE)], by inviting input via a 36-hour research charrette. Relevant historical and contemporary literature was consulted, precedents identified and critically reviewed. An interaction with the team at Wuhan responsible for makeshift hospitals and emergency infectious diseases hospitals, Central-South Architectural Design Institute, was arranged with assistance of the Chinese Embassy. Material from the [[Infrastructure Unit System Support|Infrastructure Unit System Support (IUSS)]], international literature and guidance and input gathered from the broader architectural, engineering and healthcare professional communities was synthesised and moderated by the CSIR team. The draft was reviewed by an expert review panel. 
=== Acknowledgement of contribution ===
The contributions to the initial version of this were gratefully received. [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Acknowledgements|A list of these contributors can be viewed here.]]. 
New contributions are eagerly encouraged along with debate and discussion on the [[Talk:Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites|'''discussion forum.''']] tab above.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Scope and Assumptions''' ==
ACSs as discussed in this document are dedicated, temporary facilities for triage, testing, diagnosis, further referral and treatment of persons:
*suspected of having contracted SARS-CoV-2, (persons under investigation (PUIs)), who are symptomatic and/or are awaiting results,
*or are confirmed to be infected.
ACS will accommodate a variety of clinical, logistical, support and auxiliary services associated with the render of care. ACS will currently not be licensed to provide healthcare services. Since the ACS will operate in a non-healthcare facility, it cannot fully replace a hospital setting and its prime objective is to manage the patient load until the local healthcare system can meet demands. 

=== Exclusions ===
Quarantine facilities are accommodation facilities where a member of the community can remain for a period of isolation. Such facilities will serve presumptive-case patients from each other and the general population. This comprises temporary housing for a cohort of people who do not need intensive medical attention but who cannot stay at home. Patients can take care of themselves and need limited monitoring by medical staff.

Quarantine facilities – that is for asymptomatic persons who are in the community in self- or imposed isolation, and not displaying symptoms, or who are symptomatic, but are able to safely recover without clinical intervention and do not need continuous medical observation are not considered in this document.

=== Service regime ===
The following assumptions are made with respect to services under consideration.
* Temporary - limited to the part of the pandemic when the “conventional” hospital platform cannot meet demand. To be dismantled, thereafter.
* Uncomplicated, dedicated COVID-19 care is to be prioritised for ACS.
* Patients with comorbidities, paediatrics will be prioritised for conventional facilities, and only accommodated in ACS as a matter of last resort.
* 24 hour, 7 days a week operations. 

=== Assumed mechanism of transmission ===
Transmission of SARS-CoV-2 is understood to be from person to person firstly by [https://en.wikipedia.org/wiki/Transmission_(medicine)#Droplet_infection droplet] transmission, then by the [https://en.wikipedia.org/wiki/Transmission_(medicine)#Direct_contact contact] route and finally via airborne [https://en.wikipedia.org/wiki/Transmission_(medicine)#Airborne_airborne transmission] during or following mechanical aerosolisation. Water transmission risks are minor, occurring in special [https://en.wikipedia.org/wiki/Transmission_(medicine)#Fecal%E2%80%93oral Fecal-oral] circumstances. Reclassification of transmission mechanisms may nullify some of the approaches presented in this guidance. 

=== A call for strategic coordination ===
This document focusses on infrastructure requirements. These provisions are meaningless without staffing, equipping and resourcing. Whilst staffing, equipping and resourcing are not the focus of this document, these are likely to emerge as key constraining features. Resource constraints are likely to become acute during this pandemic. Doctors and nurses are already in critical short supply in South Africa and internationally, and are themselves susceptible to COVID-19 infection. Equipment and consumables are in short supply with heightened global demand, reduced manufacturing capacity and limits in trade flows. This necessitates strategic coordination, proactive planning, options appraisal and prioritisation. 

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Status Quo''' ==
=== Rationale and transmission status ===
According to the [https://en.wikipedia.org/wiki/World_Health_Organization World Health Organisation] (WHO), based on the largest cohort of COVID-19 patients, about 40% of patients with COVID-19 may have mild disease, where treatment is mostly symptomatic and does not require inpatient care. About 40% of patients have moderate disease that may require inpatient care; 15% of patients will have severe disease that requires oxygen therapy or other inpatient interventions, and about 5% have critical disease that requires the patient to receive mechanical ventilation. However, the evolution of the outbreak in some countries has shown a higher proportion of severe and critical cases and the need to rapidly increase surge capacity to prevent rapid exhaustion of biomedical supplies and staff. In some countries, doubling rates of cases every three days has been observed<ref>WHO-2019-nCoV-HCF_operations-2020, [https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf]</ref> 

South Africa has a high burden of disease, with a high prevalence of [https://en.wikipedia.org/wiki/HIV/AIDS_in_South_Africa HIV and TB]. Although evidence is yet to emerge of the effect of SARS-CoV-2 on a population with these pre-existing conditions, there is reason to proceed with caution<ref>The Conversation 2020, https://theconversation.com/tb-hiv-and-COVID-19-urgent-questions-as-three-epidemics-collide-134554</ref>. There is a potential direct and indirect benefit of ACS to people living with HIV and TB, as well as to general public health and the health system preservation. 

With the travel lockdown in place, and continued transmission, it appears that South Africa is on the cusp between cluster transmission and community transmission according to WHO’s classification, shown in the [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites#Key_clinical_and_infection_control_activities_for_different_transmission_scenarios_.5B3.5D|table below]], indicating that preparation should include temporary hospital facilities and mass critical care.

==== Key clinical and infection control activities for different transmission scenarios <ref>WHO 2020, [https://apps.who.int/iris/handle/10665/331492 https://apps.who.int/iris/handle/10665/331492]</ref> ====
{| class="wikitable"
|-
! !! '''No Case''' !! '''Sporadic Case''' !! '''Clusters of Cases''' !! '''Community Transmission'''
|-
| Faculty Space, Including for Transmission|| Usual Space. Enhanced Screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards). || More patient care areas re-purposed for COVID-19 within the health system, especially for severe cases || Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Staff|| Usual space. Enhanced screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards)||More patient care areas repurposed for COVID-19 within the health system, especially for severe cases||Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Supplies||
*On-hand supplies. Equip wards for COVID-19 treatment.
*Identify essential equipment and supplies, including oxygen.
*Prepare expanded local supply chain
||
*Expanded inventory of supplies with detailed protocols for use.
*Activate expanded local supply chain.
*Prepare national supply chain.
||
*Conservation, adaptation, selected re-use when safe.
*Activate contingency planning and procurement for essential equipment and supplies.
*National supply chain.
*Prepare expanded supply chain at the global level
||
*Activate contingency planning should critical equipment be in short supply.
*Determine allocation of lifesaving resources for HCWs and patients.
*Activate expanded global supply chain
|-
| Standard of Care|| Usual care with enhanced awareness and recognition of immediate needs for first COVID-19 patients|| Usual care and treatment for all patients, including those with COVID-19||Identify context-relevant core services. Shift service delivery platforms. Consider reduction in elective patient encounters, including elective surgical procedures.|| Mass critical care (e.g. open ICU for cohorted patients).
|-
| Care areas expansion|| No requirements for expansion|| Designate 10 beds per suspected COVID-19 case|| Expand COVID-19 patient care areas by a factor of 35 ||Expand COVID-19 patient care areas by a factor of 58
|}

=== Quantification of need ===
At this time there are various parallel initiatives aimed at forecasting the South African epidemic, quantifying the projected need for facilities, and a shortfall in existing capacity. At this time, there is no consensus on this. This section will be updated as further data becomes available.
ACS will prioritise mild to moderately affected COVID-19 patients where basic, targeted medical care will be provided. Should patients’ needs evolve, requiring escalation of care, then the transfer of patients from ACS sites to conventional sites of care will be needed as a matter of course, bringing with it logistical challenges and risks. In the event that the conventional hospital platform is unable to cope, ACS will have pressure to provide care for severe and critical patients, and finally for patients with comorbidity and special requirements, such as paediatrics, persons living with HIV (PLHIV), TB patients and pregnant women. The following pragmatic approach, aligned with the WHO recommended strategic approach, is suggested.
*ACS should preferably be identified with space for expansion.
*The set-up should be done so that levels of care can be upgraded to higher levels of uncomplicated care.
*A secondary upgrade for more diverse package of care may become necessary.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Strategic Approach''' ==
According to WHO, clinical interventions must be put into place immediately and then scaled up according to the epidemiologic profile.
[[File:COVID-19 Resource allocation.png|none|thumb|600px|right|WHO Strategic approach to clinical care]] 
Under this declared state of disaster, the clinical care strategy which cannot be accommodated within existing facilities, can, on a temporary basis be hosted in ACS:
*Within and around existing healthcare facilities, via reconfiguration and/or augmentation.
*In existing non-healthcare buildings suitable for repurposing, such as universities, hotels and conference centres, warehouses, gyms, hostels etc.
*On open fields, including paved parking areas with rapidly constructed, dismountable structures, such as modular tented structures or using rapid modular construction techniques. 

ACS will provide isolation, general (non-acute) care for patients with mild to moderate symptoms and as required, acute care for patients with severe symptoms. Containing confirmed-case patients from general population. Confirmed-case patients can be housed together en masse, while presumptive-case patients must be individually quarantined.
As shown in the WHO Strategic approach to clinical care, the WHO recommends a range of services to meet patient need (''Citation needed''). General (non-acute) care ACS model is designed for minimal acuity patients requiring minimal activities of daily living support (e.g. COVID-positive with minimal symptoms or require <2L of oxygen). Acute care ACS model is designed for higher acuity patients requiring closer monitoring or respiratory support (e.g. COVID-positive with pneumonia or respiratory distress requiring ventilator support). Paediatric patients are to be accommodated in separate wards, where strictly controlled visitation may be allowed. 
As a preliminary estimate, the following ratios of service is proposed:
[[File:COVID Ratios of Service.png|none|thumb|600px|center|COVID Ratios of Service]]

{| class="wikitable"
|-
! '''Case severity, risk factors<ref group="Notes"> Test suspect COVID-19 cases according to diagnostic strategy</ref><ref group="Note"> Known risk factors for severe COVID-19: age over 60 years, hypertension, diabetes, cardiovascular disease, chronic respiratory disease, immunocompromising conditions.</ref>''' !! '''Recommendations'''
|-
|Mild || Patient should be instructed to self-isolate and contact COVID-19 information line for advice on testing
and referral.
|-
|Moderate, with no risk factors ||Test suspected COVID-19 cases according to diagnostic strategy. Isolation/ cohorting in:
* Health facilities, if resources allow;
* Community facilities (e.g. stadiums, gymnasiums, hotels) with access to rapid health advice
(i.e. adjacent COVID-19 designated health post/EMT-type 1, telemedicine)
*Self-isolation at home according to National guidance
|-
| Moderate, with risk factors || Patient should be instructed to self-isolate and call COVID-19 hotline for emergency referral as soon as possible
|-
|Severe || Hospitalization for isolation (or cohorting) and inpatient treatment.
|-
|Critical|| Hospitalization for isolation (or cohorting) and inpatient treatment.
|}

=== Notes and References: ===

<references group = "Note" />
<references />

=== Typology dictates & case studies ===

[[File:NHS Nightingale Hospital London.png|thumb|NHS Nightingale Hospital London <ref name="NHS Nightingale Hospital London">Coronavirus: Building NHS Nightingale Hospital London, 2020 [https://www.bbc.com/news/in-pictures-52092253 https://www.bbc.com/news]</ref>, ]]
To meet the requirements set out in this guidance, prospective “host” sites should be carefully evaluated. The type of “host” site selected will strongly influence or dictate the choice of ACS service model.

No site is likely to meet all requirements and recommendations set out in this document. Adaptations and compromises will be necessary. Services should be provided on site where it is pragmatic to do so, for example where similar services are provided. Outsourcing can also be practical/feasible for some services, such as laboratory services, catering and laundry, provided suitable logistical arrangements can be made.

Some typological responses and service models are set out in precedent examples, shown below. The examples demonstrate that a variety of host settings are workable, provided that the appropriate utility can be contrived.

=== Pragmatic approach ===
Other than in metropolitan areas, co-location of ACS on the premises of, or adjacent to existing healthcare facilities will often be preferable because this is where intensivists and specialist clinical staffing will be available, and support services may be well established. Nevertheless, augmenting capacity at existing facilities should take into account current workloads and capacity to ensure that the COVID-19 surge disrupts normal service provision as little as possible, including continuity of care for patients with chronic conditions and TB and HIV patients. 

*'''[[Infrastructure Guidance for COVID-19/Alternate Care Sites/Case Studies|SARS ACS Precedents and Case Studies can be found here]] '''

=== Notes and References ===
<references />

== '''ACS Infrastructure Planning''' ==

=== Establishing a team ===
A planning team should be formalised to establish the minimum planning and operational requirements for the ACS and to liaise with the local community. The team should include individuals with expertise in the following areas (ideally with knowledge of healthcare delivery under emergency conditions):
*Disaster response / emergency management coordination,
*Clinical care and staffing,
*Infection Prevention and Control practitioners must be involved in all stages of planning, commissioning, in-use, and decommissioning of the facility
*Facility set-up, operations and management,
*Security,
*Transport (patient, staff),
*Engineering and project management,
*Procurement and coordination of supplies, equipment and pharmaceuticals, and
*Community liaison to ensure that concerns of the adjacent population on understood an addressed.
It is important to ensure compliance with health, safety and building regulations, by ensuring the involvement of relevant local authorities. Stakeholder engagement should be formally documented. Concerns and grievances should be systematically addressed.

=== Structural integrity and operational responsibility ===

'''Structural modifications:''' ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered. 

'''Competent person:''' All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed. 

'''Asset responsibility:''' Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented. 

'''Integrity and responsibility'''

'''Structural modifications''': ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered.

'''Competent person''': All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed.

'''Asset responsibility''': Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented.

'''Decommissioning''': Decommissioning of the facility shall be assigned to the competent person discussed above. All residual structures upon decommissioning shall comply with the National Building Regulations. Upon decommissioning, removal of equipment shall be the responsibility of the owner. An infection prevention and control practitioner should be engaged in the decommissioning phase to oversee terminal cleaning and disinfection of equipment and premises.

'''Closure''': Once all patients can be safely discharged or transported back to existing facilities for continued care and there are no ongoing healthcare surge capacity needs, the ACS can be closed. Shut down of an ACS will require decommissioning, identification of new homes or storage for equipment, and termination of ongoing contracts or arrangements. Shut down should be expedited so that the facility can quickly be returned to the control of the existing owners and returned to its usual function.

Action checklist items for ACS closure should include, but not be limited to, the following:
*conduct a site walk-through with the facility owner when shutdown activities are completed to ensure that terminal cleaning and disinfection of supplies and premises, removal of equipment and supplies, and other surge closure activities have been completed to the owner’s satisfaction.
*perform medical records storage procedures.

== '''Site Selection''' ==
When selecting a site, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital can be utilised to determine whether the site is suitable for a 100, 1000 or 2000 bed facility, as required. The following indicative minimum site sizes are needed:
*100 Bed ACS/ hospital conversion, requires ± 4 300 m2
*1000 Bed ACS/ hospital conversion, requires ± 17 600 m2
Evaluation should be done by examining plans (if available), satellite images, drone images, scans and by physical inspection (walkabout). A comprehensive photographic survey should be undertaken and retained for record purposes on the site inspection. This will serve as an audit record and may assist in returning the site to its original function on ACS decommissioning and closure. When scrutinising documents and conducting site inspections to confirm the suitability of a site to host an ACS, the following criteria should be taken into account.
=== Criteria ===
*Affordability (costs, including operational costs known and budget identified),
*Sufficient physical space and capacity to house the immediate need, with the potential to accommodate physical space requirements. For example, open site should not be sloping,
*Legal rights and encumbrances, including renewal opportunity,
*Good access to highway and main roads,
*Well secured perimeter and limited controlled access points,
*Proximity to other hospitals and care sites,
*Accessibility for key staff and public transport,
*Good vehicular access around the site to set up temporary equipment such as back-up generators,
*Free from clear and present danger,
*Outside attenuation zones, floodplains,
*Outside high wind zones,
*Structure in good repair,
*Effective onsite facilities management team who understand how systems work,
*Potential for expansion, if required,
*Access to sufficient capacity for
**potable water,
**adequate sewage,
**telephone,
**internet access with sufficient bandwidth,
**electricity,
*A zone for cleaning, disinfection, and decontamination of equipment at least 15 metres away from occupied areas with access to water, a hard impervious surface and drying areas in the sun, with runoff discharge into the sewer and not into marine ecosystems or the environment. Include area for cleaning and storage of cleaning equipment.
*Likelihood of acceptance of hosting an ACS by the adjacent and local community

=== Desirable ===
*Durable, cleanable surfaces,
*Large open spaces that can be converted to accommodate temporary structures,
*Good ventilation,
*On-site kitchen and laundry,
*Housekeeping staff (chemical and equipment storage, lockers, rest facility, administration office),
*Space conducive for staff respite area and locker rooms,
*Amenities with universal access,
*Fire protection safety and equipment,
*Elevator access for patients if the building has more than one floor,
*Capacity for expansion, and
*Accessible to at least two roadways to provide continued access in the event that one roadway becomes blocked on inaccessible.

== '''Infection Prevention and Control''' ==
General guidance for COVID-19 [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|Infection Prevention and Control]] can be accessed [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|here]] 

Infection prevention and control in the context of COVID-19 should respond to transmission routes of primary concern for the pathogen of interest (droplet and contact transmission, and management of risk waste) as well as infection risk of a general nature (water and sewerage, airborne transmission – under high TB/HIV burden, and general waste).
In addition to satisfying [https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html standard precautions for all patient care], transmission-based precautions should focus on three pillars: exposure reduction by spatial configuration, operational strategies, and personal protection.
=== Transmission-based precautions ===
'''Droplet and contact spread''': Transmission of SARS-CoV-2 virus occurs via droplet and contact spread. The virus has been shown to persist on surfaces for extended periods of time and is known to be efficient at infecting people. 

'''Medical waste and linen:''' As SARS-CoV-02 is carried in body fluids and faecal matter, disposal of contaminated items (tissues) and cleaning regimes (spaces, garments, linen) should be accommodated carefully in the workflow design and infrastructure provision. A site-specific waste management plan should be formulated in accordance with a site-specific waste management plan with reference to SANS 10248. 

'''Airborne transmission:''' Under exceptional circumstances, the risk of airborne transmission arises for SARS-CoV-2, as detailed below.
{| class="wikitable"
|-
!Airborne Transmission Risk Factors
|-
|
As SARS-CoV-2 is not considered airborne, respiratory protection against airborne transmission is not considered necessary, except where aerosolisation of particles may be a risk.
According to the CDC
*tracheal intubation,
*non-invasive ventilation,
*tracheotomy,
*cardiopulmonary resuscitation, or
*manual ventilation before intubation and bronchoscopy.
According to doctors in the field also when performing
*COVID-19 diagnostic sampling as patients can be induced to cough and sneeze.
*Suspected or confirmed comorbidity of TB is not an additional risk where correct COVID-19 PPE is applied.

|}
South Africa has a high prevalence of TB and HIV, and therefore, although the risk of COVID-19 transmission via the airborne route is not paramount, there is a high likelihood that undiagnosed TB infectious patients may present at the ACS for treatment. TB triage may be challenging in the ACS as there are symptoms in common (coughing) with COVID-19. This country-specific risk is taken into account in this guidance

=== Additional precautions ===
'''Water and sewerage contamination:''' The International Water Association [[Infrastructure Guidance for COVID-19/Alternate Care Sites/COVID-19 A Water Professionals Perspective|concluded]] that water and sewerage contamination is not considered to be a key risk factor for COVID-19. The panel expressed concern for “how waste and specifically wastewater (medical) would be handled by places (e.g., hostels, hotels) that are used to serve as interim COVID-19 quarantine or testing facilities or accommodation ([ACS]. These are places other than hospitals that are used in the interim for such purposes and do not usually handle wastewater from medical settings. Such facilities should be monitored carefully.” 

== '''Spatial Strategies for Infection Prevention and Control''' ==

=== Restricted access and zone control ===
The site will be arranged to establish clear zoning, with a clear restricted zone protocol and access protection. Zones should be deemed to be "contaminated" or "uncontaminated" with clear transition areas between them.

; Contaminated zones
: (also known as "dirty areas") are areas occupied by COVID-19 infected persons, PUIs, equipment, materials and supplies which have come into contact with such persons without yet undergoing a decontamination procedure. These areas will include patient ward areas and ablutions, patient admissions (including ambulance drop-off) and the associated clinical areas. Staff rest and dining facilities should be outside the contaminated zone. Limited stock for immediate use should be kept in the contaminated zone. Layout designs should consolidate contaminated zones as far as reasonable, and avoid uncontaminated zones as islands in contaminated zones.

; Uncontaminated zones
: (also known as "clean areas") are areas not generally occupied by PUIs or confirmed COVID-19 infected persons. Equipment, materials and supplies in these areas have not yet come into contact with contaminated zones or have undergone a decontamination procedure. These will include clinical management planning rooms, stock rooms, bulk stores, pharmacy, laboratory areas, kitchen and laundry.

; Transition zones
: (also known as intermediate zone) are the spaces through which transfer of people and goods from uncontaminated to decontaminated zones, and vice versa, occur. Materials from the contaminated zone should be decontaminated or contained in the transition zone. The transfer of goods and persons should be highly ritualised and, as far as possible, traffic across transition zones should be minimised. Transition areas should be strategically located to serve this function. Separation of in-going and out-going transfer of goods and persons is preferable. Transition areas include ambulance, trolley decontamination, CSSD, laundry and waste bagging areas, patient locker area and staff change areas with spaces for donning and doffing of PPE.

=== Site layout and master-planning ===
Spatial configuration and layout can ensure unnecessary cross-over of function is avoided. This entails the systematic separation of functions and the managed transition between activities to facilitate consistency of care, an orderly, efficient work environment, less waste and reduced risk for improved outcomes. To achieve this, functional relationships should first be considered at the site level before being considered at the building level. 

<gallery mode=packed heights=300px style="text-align:left">
Layout for a SARS facility, clustering functions with minimised cross-over.png|center|thumb|Layout for a SARS facility, clustering functions with minimised cross-over <ref name="Layout1">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Layout_for_a_Patient_cohorting_strategy.png|center|thumb|Layout for a Patient cohorting strategy <ref name="Layout3">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Tygerberg Hospital virus triage unit site layout.png|center|thumb|Tygerberg Hospital virus triage unit site layout <ref name="Western Cape Provincial Government, 2020a">Western Cape Provincial Government, 2020 a</ref>
</gallery>

The WHO's Clustering Layout <ref name="Layout1"/> and Tygerberg Hospital virus triage unit<ref name="Western Cape Provincial Government, 2020a"/> show worked examples of building and site layouts, which are configured with these principles, respectively. '''Cohorting''' is defined as clustering patients with similar or compatible clinical needs together for risk reduction, acuity, efficiency and quality management, as illustrated in WHO's Cohorting Layout <ref name="Layout3"/>

=== Workflow ===
Within individual functional zones, the workflow activities can be arranged to proceed from clean procedures to contaminated procedures. In the example below, the staff arrival, PPE donning, doffing and patient flows are worked to have controlled interaction and minimised cross-over

<gallery mode=packed heights=400px >
ACS HCW Flow.png |ACS Health Care Worker Flow
COVID-19 Workflow in small unit.png |COVID-19 Workflow in Small Testing Unit <ref name="Western Cape Provincial Government, 2020b>Western Cape Provincial Government, 2020 b</ref>
COVID-19 Workflow in large unit.png |COVID-19 Workflow in Large Testing Unit <ref name="Western Cape Provincial Government, 2020b"/>
</gallery>

As far as possible, a single direction flow of clean to dirty is recommended for all processes: support services, supply and waste.
The Small ACS unit workflow diagram<ref name="Western Cape Provincial Government, 2020b"/> illustrates the recommended separation of access and exit, separate waiting seats, for persons who may be COVID-19 infected. Separate spaces are provided for donning and doffing PPE. Staff change areas are provided.

In the Large ACS unit workflow diagram <ref name="Western Cape Provincial Government, 2020b"/>, there is a clear separation between staff areas and patient areas. Waiting seats are set far apart to reduce transmission risk. Staff change rooms are provided near the point of entry to the facility for staff to change from street clothes into medical work clothes. To prevent work clothes worn inside the facility from contaminating street clothes, these are kept in separate lockers. A step-over barrier from dirty to clean sides of the change room is helpful to enforce a mind-set of avoiding cross-contamination. Bins for contaminated garments are to be provided in change rooms. Shower facilities are to be provided for staff.

== '''Operational Strategies''' ==
=== Cleaning, disinfection and decontamination ===
Surface and substrate specification, and detailing of all areas should, as far as possible, allow for frequent:
*Cleaning with detergent and water.
*Disinfection with 75% alcohol solution (metal surfaces).
*[https://en.wikipedia.org/wiki/Sodium_hypochlorite Sodium hypochlorite] (1,000 ppm)/ Household bleach.
*Disinfectants listed on the EPA List N<ref>The United States Environmental Protection Agency, [https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 List N: Disinfectants for Use Against SARS-CoV-2 (Last Visited 2020) ]</ref> (for non-critical environmental cleaning).
*High-intensity ultraviolet surface disinfection (UV-C).
*Decontamination and sterilisation of clinical equipment.

=== Goods and waste management ===
Remove any unnecessary furniture, equipment and paraphernalia from all patient care and clinical areas. Provide a clear, secure space for waste management. Any potentially infectious waste materials generated at the ACS should be considered and treated as medical waste (health care risk waste). The applicable legislation is:
*[https://www.gov.za/sites/default/files/gcis_document/201409/35405gen452.pdf The National and Provincial Health Care Risk Waste Management Regulations].
*[https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf National Department of Health COVID-19 Environmental Health Guidelines.]<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>
Waste disposal bins should be positioned near the exit inside each patient rooms or wards to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another patient in the same room.

=== Materials and finishes ===
Floor materials must be:
*Level,
*Free of dust and oil,
*Impervious and smooth,
*Slip-resistant in wet areas (e.g. patient ablutions).
Smooth, cement screed floors are acceptable. Where hosting facilities have carpeted areas, a risk assessment of factors such as durability, hygiene and decontamination needs to be conducted. In cases where the acceptance of carpeted flooring is contradicted (but other factors make it a compelling option), temporary floor finishes or covering can be investigated.

== '''Personal Protection''' ==
=== Hand sanitation ===
Where wash-hand basins are not provided, clinical wash-hand basins should be installed, at the minimum rate of provision of one wash-hand basin per 5 beds. Clinical wash-hand basins (see figure below) have a variety of features not present in standard wash-hand basins, which are preferable for infection prevention and control. Where standard wash-hand basins are provided, an upgrade is not necessary. In all cases, there should be no surfaces and no clutter, equipment or supplies in the vicinity of wash-hand basins, including surgical gloves.
<gallery mode=packed heights=400px>
Clinical hand wash basin.png|Handwash Basin <ref>de Jager 2020</ref>
Portable Wash-hand Basin.png|Portable wash hand basins can be provided in ACS <ref name="BDPa">BDP 2020, NHS nightingale instruction manual, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf</ref>
</gallery>

Where wash-hand basins are not available, portable units can be used, as shown above<ref name="BDPa"/>. Mounted brackets for hand sanitisers are to be provided for every two beds, preferably mounted near the foot rather than the head of the bed and at all common touch points such as entry points at ablution facilities, linen room, sluice, storerooms, medicine rooms/cupboards, near refrigerators, telephones, light switches, at entry/exit doors, etc.

=== Personal protective equipment ===
Donning and doffing points for personal protective equipment, and convenient, safe disposal of consumables to be placed at critical key points when entering patient areas.
----

== '''General Transmission Mitigation''' ==
=== Water and sanitation ===
To comply with National Building Regulations; Hazardous Biological Agents Regulations and National Department of Health COVID-19 Environmental Health Guidelines<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>.

=== Droplet aerosolisation ===
When designating areas for procedures during which aerosolization and airborne transmission risk is high, the building ventilation must be carefully considered to take into account downstream risks. In particular, consider to where potentially contaminated air, arising from aerosol-generating procedures, is exhausted. In general, air exhausted directly to the outside is diluted and considered safe, unless there are openings to occupied spaces near the exhaust air outlet. 

In the event that potentially occupied spaces will receive partially diluted or undiluted contaminated air, or where this is indeterminate, the aerosolising activity should be designated to an alternate area. In the event that an alternative is not available, some treatment regime (air filtration or air disinfection) is necessary. 

In most naturally ventilated settings, the airflow direction between zones may fluctuate according to the wind direction. Such high-risk spaces should not be adjacent to spaces with high susceptibility rates, such as PUI areas and uncontaminated areas. Contaminated areas should not be directly adjacent to clean areas unless mechanically ventilated. 
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|Guidance on COVID-19 building ventilation design is provided here]].

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Health, Safety and Well-being''' ==
In addition to the infection prevention and control measures discussed above, the following should be provided for health, safety and well-being.
=== General provisions ===
*Minimised and controlled entry and exit points, with suitable control.
*Clearly identified accessible and marked routes for patients, staff, goods and waste.
*Clear designation of restricted zones.
=== Site level provisions ===
*Safe staff parking and arrival of staff via planned and public transport.
*Clearly demarcated parking for people with disabilities.
*Arrival and departure point for patients via public transport, passenger vehicles, and emergency service.
*Limited safe patient parking.
*Supply of goods and removal of waste.

=== Within and between buildings ===
*Entrances with a clear opening width (CoW) of at least 900mm.
*Routes with a minimum width of 2 000mm free of hazards, for example, rubbish bins.
*All clinical, patient and support areas to be accessible by trolley.
'''Ramps''' should be of stable construction, capable of sustaining a mass of 300kg. They should incorporate side lips and the surface should be slip-resistant. Gradients should be as gentle as the circumstances allow. (Recommended maximum 1:20). 
'''Small changes in floor levels''' are not desirable, but where these exist are to be clearly marked with reflective paint/ tape, and lit at night
Elevators between different floors, where patients need access (The recommended minimum lift size for patient trolley/stretcher movement is 1 400mm × 2 400mm, however, this may not be possible). 
'''Pathways''' to be lit at night, where used at night. 
'''Staircases''' must be well-lit at night with non-slip surfaces and secure balustrades. 
'''Doors''', Double doors and automated or push-operated doors to all clinical areas are to be preferred, where these are newly installed or able to be retrofitted. Door closers are to be disabled, where not necessary to reduce touch surfaces. Hand sanitisers to be provided at where high touch common surfaces occur (e.g. wall-mounted at doorways).

=== Signage ===
The appropriate level of information to facilitate legibility, orientation and wayfinding. Minimum standards, signage to be:
*Clearly visible, simple font, font size, contrasting colours, placed in the field of vision
*Washable
*Comprehensive safety signage - fire signage (exits, equipment etc.)
*Restricted areas clearly marked
*Identification signage - each patient space to be allocated a unique number and a whiteboard or perspex sheet for writing the patient’s name
Signs should be posted immediately outside of patient rooms indicating appropriate IPC precautions and required personal protective equipment (PPE).
Signage of a temporary nature can be provided on laminated white A4 sheets attached eye-level. The text should be black sans-serif (for instance Arial) text at least 40point size and centrally positioned on the sheet. Detailed guidance on signage is provided in IUSS Inclusive environments.
=== Safety and security ===
Upon identification of the ACS host site, a team should be convened to conduct a multidisciplinary safety and security analysis. These critical team members need to form the working committee responsible for undertaking the detailed assessment of the existing facility’s security. They should analyse data about the security system’s condition and review existing security concerns or issues that are reasonably likely to become concerns in the near future. The figure below represents a five-zone approach to security, which is a recommended, systematic approach to security.
[[File:Zonal approach to security.png|center|600px|thumb|IUSS Security- Zonal Approach to Security <ref name="IUSS Security">IUSS Hospital design principles - Security [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file]</ref>]]
The security strategy should take into account that whilst clinical services and some logistical and support services will be required 24 hours a day, seven days per week, some support services, logistics services and auxiliary services may only be operational for the minimum periods required to meet demand. These functional elements should be capable of being secured, for example over weekends and at night, as the case may be.
Detailed guidance is available in [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file IUSS Hospital design principles - Security] <ref name="IUSS Security"/>

=== Comfort and dignity ===
Supplemental heating: Patient health and comfort are dependent on, amongst others, maintaining body temperature. The ACS structural technology must be selected to achieve the general indoor environment conditions discussed in a subsequent section for all clinical and occupied areas. As we are moving into South African winter supplemental heating may be required, especially in the evenings, in order to avoid hypothermia. Use of fans, bar, radiator or gas heaters should be prohibited. Unless clinical areas can be maintained above 18 degrees centigrade, patients should each have an infrared heater available, in addition to blankets. Personal/ donated blankets can be considered if they are laundered first and could be destroyed upon discharge.
Mobile screens should be available to provide privacy where necessary (e.g. during consultations or procedures).
<gallery mode = packed heights = 400px>
Bed_Isolator_-Vietnam.png|thumb|Flexible Barrier Isolator<ref>WHO. (2020), Severe Acute Respiratory Infections Treatment Centre. Geneva, Switzerland : WHO- World Health Organization</ref>
ACS Cohort beds.png|ACS Cohort beds.png|thumb|Excel Centre London 04-2020 <ref>Architects' Journal 2020, [https://www.architectsjournal.co.uk/news/nhs-nightingale-bdp-on-the-first-nine-days-converting-the-excel-centre/10046749.article https://www.architectsjournal.co.uk/news]</ref>
</gallery>
Some solutions which address patient privacy and dignity are depicted above.

=== Notes ===
<references/>

== '''Schedule of Accommodation''' ==
Based on clinical needs of the ACS, a schedule of accommodation can be crafted capturing the clinical, clinical, logistical, support and auxiliary services associated with the render of care. When deriving a schedule of accommodation, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital tool can be used. Functions to be accommodated are: 
'''Clinical services''': Triage, rapid assessment of persons entering the facility, to expeditiously identify and render the appropriate service. Admissions and registration. Inpatient accommodation is to be organised according to cohorting principles, discussed above. Testing and diagnostics, including laboratories and x-ray. Safe storage and dispensing of drugs to patients.Offices for clinical administration and clinical planning meeting rooms in the clean zone are needed. 
'''Logistical services:''' Logistical services will entail management of flows of people, goods, services and information to and from the site, as well as within the site. It includes security and communication arrangements. Staff entry, preparations to transition from outside to clinical work environment, including pause areas for relief. Emergency services, visitors. Goods, supplies and storage and waste removal and/ or treatment.
Support services key to the provision of clinical services should be separated so that the risks associated with that particular activity can be managed. 
'''Support services are:'''
*Laboratory services
*Catering
*Laundry
*Environmental cleaning and housekeeping
*CSSD
*Maintenance and cleaning of surrounds, eg. waste areas
*Porters/”runners”, stretchers/wheelchairs
*Mortuary
* Security
Support services can be provided off-site, in which case, safe, secure and efficient transfer and logistical arrangements should be designed. 
'''Auxiliary services:''' Auxiliary services are services which may be provided on or near the ACS site, but which are not directly related to core clinical care. This included overnight accommodation for staff who may not wish to return home to avoid exposing their families, or who need rest between shifts, or for discharged patients awaiting transport home, volunteers who have recovered from SARS-CoV-2.
Limited psychosocial services and allied health services may also be provided on or near ACS for example by approved partners.
Examples of schedules of accommodation for patient and support spaces for a protective isolation ward is available [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedule for COVID-19 Isolation Wards|here]] and mild to severe cases [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedules for COVID-19 Wards for Mild to Severe Cases|here]].

== '''Clinical Services''' ==
=== Triage ===
Confirmed COVID-19 cases and PUIs who are referred from a testing facility or a higher level of care, will enter the facility in a triage area to receive vital screening and initial assessment. They will be registered and admitted to inpatient care. They will be assigned a "ward" or section of the facility - based on disease status and acuity. These are Protective Isolation, the Mild & Moderate ward, or the Critical & Severe wards. Patients should be clustered according to gender. As far as practicable, ablutions for each gender, isolation patients, paediatrics and staff shall be separately provided. Paediatrics patients, if admitted, are to be assigned a dedicated section.
As patients recover or deteriorate, they may be relocated to the appropriate section/ ward.
Once the patient has sufficiently recovered and a negative test result is received they will be appropriately decontaminated and discharged, collecting medication from the dispensary on exit. Patient movement between various sections of the ACS will be restricted as far as possible, with mobile radiology units, in-ward medication dispensing and in-ward food service.

=== Inpatient ACS accommodation ===
Separate spaces for:
*suspected, unconfirmed cases, under observation (PUIs), to be accommodated in isolation facilities (separate rooms, if possible);
*patients with confirmed COVID-19 with mild to moderate disease, not requiring dedicated oxygen therapy;
*patients who require dedicated oxygen therapy;
*patients requiring mechanical ventilation; and
*recovered/ confirmed negative.
==== Protective Isolation Facilities ====
Suspected, unconfirmed cases, under observation – persons under investigation (PUIs) to be accommodated in protective isolation facilities (separate positive-pressure rooms, if possible). PUI are restricted to their rooms. All food and laundry services will be brought to the PUI rooms to reduce interaction and potential contamination. All waste will be collected by facility staff and taken to waste handling areas. Infection prevention and control measures are put in place for the handling of used food utensil and laundry as well as waste collection. PUI areas will have restricted access, including for staff serving other inpatient sections, for confirmed cases.

==== Inpatients accommodation for confirmed COVID-19 ====

Inpatient facilities confirmed positive COVID-19 can be accommodated in large shared ‘wards’ with partitioning between patients. Partitioning between patients is optional. Partitioning is preferable to curtains found in conventional hospitals, as they are more conducive to daily cleaning. If curtains are used, antimicrobial treated fabrics with biocide used to treat the curtains has been tested to international standard EN 14476 and shown to be effective against H1N1 Influenza A Virus (Swine Flu), >99.999% kill rate in 5 minutes and measles morbillivirus, >99.99% kill rate in 5 minutes are preferred. If only separate rooms are available, patient monitoring and surveillance will need to be accommodated. This phase of treatment has a lower area/space requirement compared with PUIs, as cross-infection between patients is less of a concern. Shared ablution facilities are acceptable. It is recommended that, at least, two general accommodation ward areas be provided. 

a) Mild and moderate patients, and 
b) Serious and critical patients. 

The room must have openable windows for natural ventilation if a dedicated positive pressure ventilation system is not available. Ducted ventilation systems shall not be shared between PUI areas and confirmed COVID-19 patient areas. 
[[File:COVID-19 ACS - protective isolation – bed layout.png|thumb|center|800px|ACS - protective isolation – bed layout]]
[[File:COVID-19 ACS – mild-moderate patient bed layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient bed layout]]
[[File:COVID-19 ACS – mild-moderate patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient shared ward layout]]
[[File:COVID-19 ACS – severe-critical patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – severe-critical patient shared ward layout]]

Examples above show bed layout with bed spacing for protective isolation, a mild/moderate patient and a mild/moderate patient shared ward and for a severe/critical patient

=== Patient services ===
Patients in ACS will not generally be ambulatory and will be confined to their room, or cubicle in a bed. In general, domestic beds or hospitality industry (hotel) beds are not suitable for patient care. These should only be used where a hospital-grade bed cannot be sourced, as hospital beds are designed for ease of cleaning and decontamination (for infection prevention and control) and with patient and ergonomics, safety and comfort taken into account (they prevent back injury for nursing staff and can help to prevent bedsores). The higher the specification of bed, the more suitable it is for the higher levels of care. Lockers for patients personal belongings should be provided in the uncontaminated zone (in which case bedside lockers will not be necessary), and it is preferable (where bedside lockers are not provided) for overbed tables to be provided, per bed, if possible. 
The following beds are suitable:
*Repaired and refurbished beds from condemned hospital stocks.
*South African National Standard, SANS 521:2013 Edition 3.5, on Hospital beds and cots ISBN 978-0-626-28830-3.
*Beds listed on the National Treasury (See [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Hospital Bed Specification|specification]]).
The table below details the minimum services required at each patient bed. Details on these services are discussed in a subsequent section of the document.

{| class="wikitable"
|-
! Service/ Capacity!!Triage!!Isolation !!Mild – moderate inpatient!!Severe case wards!!Critical case wards
|-
| Power – 16A 230V Single socket outlet||As needed ||1 per bed||1 per bed||3 per bed||6 per bed
|-
| UPS Power – 16A 230V Single socket outlet ||As needed||1 per bed||1 per bed||1 per bed||2 per bed
|-
| Medical Air<ref group="Note">Mobile units recommended for intermittent use. 3 per 20 beds</ref><ref group="Note">There are some ventilators which have built-in compressors allowing them to function without Medical Air. This is however, not the norm. With Ventilators probably being the most difficult medical device to obtain at present, it would be prudent to rather allow for Medical Air at each bed.</ref> (LP)400kPa||No||Yes||No||Yes||Yes
|-
| Medical O2 -400kPa||Portable/shared||Portable/shared||No||One||Two
|-
| Vacuum-40kPa||No||Portable/shared||Portable/shared||Yes||Yes
|-
| Equipment rail||||||||Yes||Yes
|-
| Upper room UVGI||Optional||Optional||||||Optional
|-
| Examination light||No||No||Yes||Yes||Yes
|-
| Room Ventilation rate||60 L/s per person||10 L/s per person||10 L/s per person||10 L/s per person||12 ACH
|}
'''Notes: '''
<references group="Note" />

Two additional 16A 230V single socket outlets, one two-pin outlet and a worktop should be provided for every 32 beds (or part thereof), for:
*Electrocardiograph (ECG): Could be omitted if monitors have a full 12 lead ECG function.
*Blood gas analyser: Could be omitted if a Lab Services are available.
*Staff cellphone charging.

Example of healthcare technology to be provided for critical care patients is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]. Severe patients may be provided continuous positive airway pressure (CPAP). Emergency trolleys (“crash carts”) are to be provided in patient areas with convenient access to patient beds, out of the passage of corridors and is moved to the patient when needed. 1 crash cart for every 16 patients (or part thereof, with at least one dedicated for PUIs. An example of provisions for a crash cart is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]
==== Patient ablutions ====
[[SARS-CoV-2 is found in faecal matter]], so careful management of patient body fluids is crucial and convenient, practical support for frequent cleaning of ablutions especially shared ablutions is necessary. Dedicated ablutions (toilets and showers) are to be provided for patient use. Toilets and showers should be in separate rooms.
Hand washbasins and or/ hand sanitiser should be provided both inside and outside the toilet room so that patients can wash their hands on the way in and on the way out of the room.
*1 toilet for every 8 persons.
*1 shower for every 8 persons.
*1 disabled ablution for every 8 regular ablutions (or part thereof).
*1 disabled shower for every 8 persons (or part thereof).

Critical and severe patients may be sedated and have a reduced need to access ablutions, ablution facilities proximity and provision can take this factor into account. Showers and wash hand basins should have hot and cold running water. Where possible ablution facilities must have openable windows for natural ventilation, if not possible the bathroom extraction and room ventilation system must be reviewed before admitting patient '''(see [[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|ventilation]]).'''

Portable toilets and showers may be used, provided that suitable hand wash facilities are provided. These will need to be suitably located, preferably in decentralised clusters, so that patients can easily access them without needing to walk very far. Ablutions should be located and designed in such a way as to provide visual and acoustic privacy, dignity and avoid disturbance of other nearby patients when accessing, using or cleaning the ablutions. Separate ablutions are to be provided for PUIs and confirmed patients.

====Makeshift sluice areas ====
In conventional hospital settings, sluice rooms are provided for cleaning and sanitation of soiled equipment, such as bedpans. In a temporary setting, such as an ACS, the establishment of a temporary sluice room may not be practicable, and there may not be facilities for emptying buckets, rinsing equipment etc.. The following is suggested:
Allocate a toilet, hand wash basin, not in splash range and restrict access to it for draining buckets and install a macerator for disposal of disposable bedpans. Electrical, water and waste supply points required as per supplier specification.
==== Dedicated patient treatment areas ====
The following dedicated, private spaces per ward for clinical procedures are recommended:
*Counselling and consulting room (can be shared), as shown in the figure below
[[File:Consulting room example layout.png|400px|thumb|center|Consulting room example layout]]
*Minor procedures room, as per the example provided in the figure below 
[[File:Treatment-minor procedures room example layout.png|400px|thumb|center|Treatment / minor procedures room example layout]]

== '''Logistical Services''' ==
=== Communications ===
Electronic communication should be facilitated in all zones of the ACS by the provision of device charging stations, and wifi.
=== Visitors entry point ===
Visitors are strongly discouraged from entering the ACS.
*In paediatric wards, one parent may be accommodated to visit a patient. In such cases, direct access for the visitor should be provided so that the visitor does not need to pass through the general patient area. Appropriate PPE must be donned before entering the patient area and hand washing/sanitising must be done when exiting the area.
*Non-patients who are accompanying suspected patients to the facility for testing or admission must be accommodated in a well-ventilated, spacious waiting area. Signage in such waiting areas must inform visitors about symptoms, hand hygiene and PPE.
*Hand washing/sanitizing facilities should be provided.

=== Staff areas ===
==== Staff change rooms ====
A minimum of 9m² or 4m² for a single person, increasing by one m² for each additional person is required. The clean (street side) and dirty (contaminated facility side) of the change room should be separated by a step-over barrier.

==== Staff rest areas ====
Staff rest areas within the main facility should be provided with access to kitchenette facilities and staff ablutions.
=== Staff auxiliary services ===
'''Staff on-call:'''Since staff may be required to work long hours or could be required to be on-call, shared, overnight sleeping facilities can be provided for staff on duty, outside the contaminated area, but in close proximity on the patient areas. An example is set out in the diagram below.
[[File:Example of on-call sleeping area for staff.png|center|600px|thumb|Example of overnight sleeping area for staff]]

'''Staff accommodation:''' It is advisable to provide some staff accommodation for off-duty staff who may not have suitable alternatives, for example homes too far away, transport limitations or the requirement not to expose family members to risk. This should be provided in the vicinity of the ACS, but in a physically separated zone. This amenity can be outsourced.

== '''Support Services''' ==
=== Workflow principle ===
[[File:Linen processing cycle.png|none|thumb|Linen processing cycle <ref>IUSS 2014 [https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department]</ref>]]
Progressive workflow from “dirty” (that is contaminated) to “clean” linen is advisable to reduce the risk of exposure to contaminated materials. The workflow diagram below, showing the progression from the dirty linen receiving area, to the cleaning process, to decontamination and drying, and finally sorting and packing, and storage, illustrates this principle.
=== Laboratory ===
[[File:Example of modular laboratory.png|right|thumb|Example of modular laboratory]]
The WHO recommends the following laboratory diagnostic equipment be accommodated:<ref>WHO 2020, [https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items]</ref>.
<nowiki>• Lab screening test kit
• Lab confirmation test kit
• RT-PCR kit
• Extraction kit
• Cartridges for RT-PCR automatic systems
• Swab and Viral transport medium
</nowiki>
Additional accommodation requirements are:
# Reception counter- receiving specimens
# Testing with perspex/ glass screen
# Receiving/Data capture
# Specimen holding
# Toilet - staff
# Blood storage fridge
Can be provided as a modular laboratory unit as shown in the diagram.
=== Pharmacy ===
The purpose of the pharmacy is to provide medicines needed for inpatient treatment and care.
All medical supplies should be stored in a secure, climate-controlled area in close proximity to the patient treatment area. The pharmacy must have dry, lockable, climate-controlled storage of medications. Most pharmaceuticals are labelled with storage temperatures. The pharmacy should have adequate ventilation through an openable window to prevent humidity from building up in the room. Air-conditioning or mechanical ventilation can be provided, if necessary.

Dispensing areas must be well lit. Worktop in space for stock records and administration. Dispensing counters to have perspex or glass screens to serveries. Social distancing implemented at counter, between pharmacists/assistants and between chairs in waiting area.

Can be provided in a mobile unit.

=== Radiology ===
The purpose of radiology services is to provide chest X-Ray services for COVID-19 diagnostics. In general, CT scans, bucky rooms etc. associated with some radiology equipment require specialised infrastructure and therefore is not suitable for ACS. Radiology services can be provided as a mobile floor standing unit, or containerised unit. Alternative technologies such as Lodox and hand-held ultrasound devices are being investigated as potential options and could be confirmed as suitable for use in due course.
=== Laundry services ===
All dirty linen should be handled for bagging or binning inside the patient room/cohort area. The clean linen stock should be stored conveniently close to clinical areas, in a dedicated clean area in the uncontaminated zone. Used linen should be stored in a designated, safe, lockable holding area while awaiting collection. Interim storage areas for soiled linen at the wards is allowable; this may be in dirty linen/ utility room.
Any clean linen for PUI areas should be handled in spaces physically separate from dirty linen of confirmed patient areas. It may be necessary to completely separate PUI and confirmed patient linen streams. Soiled linen and clean linen bags and bins should be dedicated and not mixed.
Full laundry cleaning and drying services may be provided on-site or outsourced. If laundry cleaning and drying services were already rendered on or for the host site before it is repurposed as an ACS, then a suitability and risk assessment should be conducted to ensure that the volumes of laundry generated and infection prevention and control measures are conducive and modifications made as necessary. A new full laundry service may take time and resources to establish, and in general, will not be established at a host site as a temporary solution. Where the site and circumstances advocate for the design of a new laundry or the upgrade of an existing laundry, the IUSS Laundry Services for Hospitals should be applied.
==== Siting and model selection considerations ====
When an existing laundry is being assessed for use or a new one is being planned the following considerations apply:
* Water and power capacity.
* Ease of access to the ACS’s main corridors and internal transport routes.
* The noise factor of the facility and its impact on nearby patient care departments.
For outsourced departments:
* Delivery areas to allow sufficient space to ensure that vehicles can manoeuvre and park easily at the reception and dispatch bays.
* Access to the ACS service roads and public roads.
==== Functional requirements ====
The most basic equipment needed in a laundry includes washing machines, tumble dryers and ironing machines. Equipment requiring steam is not recommended for a temporary facility. The sizing of the laundry, equipment and engineering services can be modified based on the principles provided in the IUSS Laundry and linen.
=== Catering services ===
Kitchenettes, that is, areas for tea, coffee and snacks, mainly for staff, in staff pause areas are discussed elsewhere in this document.
Catering services (for staff and patients) may be provided on- or off-site. If the ACS is to be established with easy access to a suitable, existing, functional kitchen service (e.g. hotel, military or hospital catering) which can meet the additional demand of the ACS, then this should be used. If there is no suitable facility, catering should be outsourced via a suitable off-site supplier. Only in the event that no feasible or suitable, existing facility or local supplier is available, should a new catering service be established at the ACS. Detailed guidance for the sizing, design and layout of catering services can be found in the IUSS Catering Services for Hospitals.
The kitchen (for on-site catering) or preparation area (for off-site catering) should be located with easy access to the point of delivery and storage of food. Adequate food and equipment storage space must be provided.
It is recommended that patient and staff meals, where provided, be supplied in disposable, containers, suitable for incineration, and that these are disposed of as risk waste immediately after use.
Where off-site catering is used, a suitable area for receiving should be provided. Space will be required for sorting meals for distribution and collecting and storing dirty dishes, washing dirty dishes, if necessary, and disposing of left-over food and disposable containers and utensils. The size of the areas required for this will depend on the number of meals delivered.

=== CSSD ===
The primary function of a Central Sterile Supply Department (CSSD) is to provide an efficient, economic, continuous and quality supply of disinfected and sterilised items, when needed, to all patient-care service points in the ACS, and to receive returned contaminated items for cleaning.
CSSD with limited sterilisation capacity (autoclave) but sufficient disinfection capacity (instrument washing). The layout requires a designated clean and dirty areas with a hard barrier between to avoid cross-over of staff and equipment. Work is unidirectional - flows from dirty – to clean - to sterile areas.
This yields three distinct zones:
1. Receiving and cleaning with pass-through windows
# Dirty receiving with Perspex or glass partitioning
# Dirty utility
# Decontamination and cleaning/wash area with throughput instrument washing
# Trolley wash/Park – external
2. Inspection, assembly and packaging with pass-through windows
# A tabletop autoclave
# Instrument washer
# Clean Packing area
3. Sterile processing, storage and distribution. (Separate issuing area from receiving area) with pass-through windows
# Store -linen and consumables
# Sterile pack store
# Issue - Collection hatch with Perspex or glass partitioning
Must also have a secure, separate receiving area for consumables receiving and storage.
An example of a CSSD unit is shown in Figure 21.T

[[File:An example of a small CSSD facility.png|600px|thumb|none|An example of a small CSSD facility<ref>IUSS 2014, https://www.iussonline.co.za/norms-standards/support-services/24-central-sterile-service-department</ref>]]

To be understood: Quality of services, eg. water (including a source of distilled or ionised water for rinsing of bronchoscopes) and electricity, quality of management, if equipment is appropriate for needs and fit for purpose, what is required of the equipment in the near and far future (relocation?), compliance with S.A. National Standards for CSSD, compatibility of equipment and devices, correct chemicals, maintenance of equipment, training of operators. Although the use of disposable breathing circuits and accessories (masks) should be encouraged, the capacity to disinfect these items if disposable is not available must be considered.

The CSSD must be sized to serve the ACS. Considerations are workload and space requirements. CFSA has extensive [https://www.fidssa.co.za/Content/Images/CFSA_SOP_2018.pdf standard operating procedures] for CSSD.

Workload: Number and type of procedures, number of procedure rooms, eg for bronchoscopy, operating hours, available inventory, volume of work and peak times, degree of mechanization, eg. manual or automated instrument washing, amount of product to be stored – chemicals, barrier wrap, chemical indicators, etc., storage and distribution records, quality records – eg. equipment checks, disposal needs.

Space requirements: Space for separation of clean and dirty, allow for unidirectional movement, allow space to manoeuvre trolleys (queue, pack/unload), reduce lifting and carrying heavy items, reduce awkward movements, allow for tidy work areas. Insufficient space will compromise sterility!

Preference should be given to construction materials and finishes which are suitable for frequent cleaning and tolerant to chemicals, including bleach (sodium hypochlorite). Impermeable flooring, non-slip and smooth washable walls are needed. Joints at walls and floors and coving at wall edge, and exposed drains should be avoided. Worktops should be sealed and should be ergonomically suitable.

Ceiling heights below 2.8m may be vulnerable to damage from humidity Where steam and moisture are generated. Noise – insulation of washer-disinfector and steriliser in technical walls will reduce noise. Lighting: Natural light if possible – windows sealed. High luminance if artificial lighting. Open, slatted shelves for sterile store area. Sinks for manual washing: At least two basins, deep (25cm at least) basins, 91 cm from floor, wide and long enough for the biggest instrument tray or container, water ports for flushing of lumens.

The CSSD space allocation and layout should be determine based on what procedures and which medical devices will be required. A typical [[equipment list is provided here]].

=== Maintenance and cleaning ===
Maintenance and cleaning services must be accommodated with offices located away from clinical areas.

=== Mortuary services ===
The National Department of Health has issued guidance on handling of dead bodies and infectious remains<ref>National Department of Health South Africa, 2020 [https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf]</ref>, which should be applied to ACS. While some guidelines have recommend that bodies of persons who have died from COVID-19 should only be held for a very brief period prior to cremation or treatment for burial<ref>Zhejiang University, 2020 [http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm]</ref>, the WHO holds the view (at the time of writing) that there is no evidence of persons becoming infected from exposure to bodies during normal ceremonial and burial activities. However, appropriate PPE should be used when handling such bodies with additional airborne precautions to be taken during autopsies<ref>WHO, 24 March 2020 [https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf]</ref>.

Either body cabinets or a refrigerated room could be used for body storage. 

==== Comprehensive Mortuary Facilities Guidance====
View the [[Mortuaries|Mortuaries Guide]] for comprehensive mortuaries design and planning guidance 

==== Location and layout of mortuary service ====
It is likely that not all alternative care sites will have a mortuary. Those without a mortuary must have a holding room that is located away from general access areas. This holding room must be suitably sized and conditioned. A recommended room size is 3.5 m x 3.4 m<ref>IUSS Adult Inpatient Services, 2014, [https://www.iussonline.co.za/docman/document/clinical-services/65-adult-inpatent-services-gazetted/file]</ref>
A mortuary should be located so that it is easily accessible to mortuary staff and related service providers and visitors without presenting either aesthetic, emotional or ethical problems for unrelated staff, patients or visitors. It should be separate from the general facility, allowing access for the family to view a body without passing through any potentially contaminated area of the facility. The visitors’ entrance should be external and completely separate from other access points.
Appropriate routes should be designated so that bodies are not moved through public-access areas.
==== Sizing of mortuary ====
The layout and size of a mortuary are largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.
==== Services ====
The following services are required in a mortuary:
* Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.
* Sluicing facilities are to be provided in both the body-preparation and autopsy areas if they are not a common area.
* Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush-fitted stainless steel grids.
* No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.
* The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.
* Anti-backflow devices should be fitted to the water-supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.
* Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.
==== Finishes ====
Wall and floor finishes should be impervious to liquids and easily cleanable.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Engineering and environmental controls''' ==

=== General indoor environment conditions ===

Existing environmental control systems should be modified to suit requirements in the facility. The following issues should be considered:
* Systems should be set to maximise the introduction of fresh air and maintain the pressure regime (see ventilation).
* The following internal temperature range should be maintained 19 - 24oC.
* Cooling systems should be able to cater for projected internal heat gains from people, lighting and equipment. Indicative heat gains in treatment areas are 8W/m2 from people, 15W/m2 from lighting and 3 W/m2 equipment and in critical care areas 16W/m2 from people, 15W/m2 from lighting and 60W/m2 equipment.
*As heat gain can vary widely between items of equipment, heat gain and utilisation rates for equipment should be obtained from the manufacturer to establish this more accurately.

=== Solid waste from ACS ===
According to the National Department of Health COVID-19 Environmental Health Guidelines
“All solid waste from the facility should be regarded as potentially infectious material and therefore appropriate precautions should be taken". The management of healthcare risk waste (HCRW) should follow the correct identification segregation, storage and disposal processes as indicated in SANS 10248-1.

* HCRW is segregated at the point of generation and shall be containerized to minimize the risk of contamination.
* Waste generated from patients in isolation or quarantine in a designated facility health facility is treated as health care risk waste (HCRW) as per SANS 10248-1-2008.
* The HCRW is properly packaged in a sealed, leak and puncture-proof containers/ boxes.
* The HCRW is labelled with the biohazard symbol/ sign and marked “Corona virus or COVID-19”.
* The HCRW is stored separately from other waste generated.
* The collection, transportation, treatment and disposal is provided by only an appointed/ appropriate contractor/ service provider, however, ensure that waste is safely stored until the health care waste management company can pick it up and that the company knows and acknowledges that waste was generated by suspected or confirmed COVID-19.
* The waste management company collecting must ensure that and treated and disposal is conducted at license waste treatment/ disposal facilities .
* All personnel or staff in contact with patients must be geared with appreciate personal protective equipment (PPE’s) at all times to prevent exposure or risk to health.
* Monitoring should be done at such facilities.
* All, bags, bins and boxes must be adequately sealed, as not to leak any fluids, and must be wiped down with 0.05% chlorine solution

Measures developed should consider the following.
* Develop a waste management plan following national guidelines and best practice standards for the disposal of medical waste (WHO, 2020).
* Establish procedures with medical waste service providers to regularly pick up the waste and dispose of this safely.
* Provision should be made for 5kg of solid waste per bed per day and this should be monitored and supplemented where it appears this may be inadequate.
* Ensure that access to waste is secure and controlled, for instance, by using lockable waste 1000l containers kept in a location that can only be accessed by health facility and nominated service delivery staff.
* Vermin control programs must be implemented throughout the site with HCRW collection points prioritised
* Provision for safe cleaning and disinfection of reusable containers should be provided. Cardboard, single-use HCRW boxes are removed from site and incinerated.
* Waste must not be allowed to accumulate or be stored inappropriate or unsecured containers.

== '''Engineering Services''' ==
Engineering services include patient services, ventilation, electrical power, water, medical gases, oxygen, compressed air, vacuum, lighting, and fire safety that support the needs of the patients and medical staff under normal and emergency situations. Good practice standards are provided in:
* IUSS Building Engineering Services<ref name = "IUSSBES">IUSS 2017, [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file]</ref>
* NHS Nightingale Instruction Manual<ref name="BDP2020">BDP 2020, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf]</ref>.
The guidance below draws on these and other manuals and standards. 

=== Building ventilation ===
==== Mechanical ventilation ====
While SARS-CoV-2 RNA has been detected in aerosol form, in experimental mechanical aerosolization studies, it is primarily spread through droplet and contact spread and the potential for airborne transmission is thought to be low.
However, the following advice is provided by ASHRAE regarding HVAC systems in general spaces (not specific to healthcare):
Effective high levels of ventilation must be achieved in the facility. Existing ventilation systems should be tailored to suit internal layouts and requirements and the following measures should be taken.
* Mechanical systems should be set to maximise fresh air supply to the facility. There should be no recirculated air without HEPA filtration or other validated decontamination processes.
* A pressure regime should be established, as shown in figure 2, to 'push' air from clean areas, to dirty areas and then out of the building.
* A clean air supply of over 10 L/s per person should be targeted for odour control.
* Fresh air supply shall not be located near patient beds to avoid drafts in winter.
* Extraction points can be located near patient beds in isolation wards or at a high level in long-stay wards. Short-circuiting of air between high-level supply and extraction is a performance risk in winter.
* Noise from ventilation systems and fans shall be below 45 dBA
* Protected lobbies, internal partitions, door arrangements, fans and extracts should be used to maintain the pressure regime and airflow as indicated in the diagram below.
 

[[File:Ventilation in temporary facilities.png|600px|thumb|none|Ventilation in temporary facilities<ref name="BDP2020"/>]]

==== Natural ventilation ====
The airflow direction between naturally ventilated zones may fluctuate according to the wind direction. This is not of concern within and between contaminated zones where occupants are either protected with mandatory PPE or confirmed to be infected with disease strains similar enough so as not be able to reinfect others. Where levels of occupant susceptibility to an airborne disease is significantly different, the less susceptible areas (such as PUI areas and uncontaminated areas) shall be protected from the naturally ventilated and contaminated areas by mechanical ventilation systems with a capacity sufficient to overcome the expected natural ventilation pressure fluctuations (typically 5-15Pa). Where such mechanical ventilation systems are not feasible or expected wind pressure is too great, zone adjacently must be avoided.

===Ultraviolet germicidal Irradiation===
The application of Ultraviolet Germicidal Irradiation (UVGI) for room air disinfection is well understood and is proven to be effective in the disinfection of microorganisms including M. tuberculosis (TB) in air. UVGI should, therefore, be considered as a valid element in indoor airborne infection control strategy for high volume settings. Studies have demonstrated the importance of good vertical air mixing in the room, and the safety of UVGI application. In areas where UVGI is indicated, the design and development of UVGI systems should be in accordance with the [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]<ref>van Reenen et al,2019 [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]</ref>

=== Electrical power ===
Sufficient and reliable power must be available at the facility for envisaged medical equipment, medical gases, lighting and building ventilation equipment. Power installations for the temporary facility can be divided into three zones as indicated below. These are existing services, the temporary service zone and services in each bay.
The following should be considered by competent engineering professionals.

=== Existing services ===
*Capacity: Evaluate whether sufficient power to accommodate envisaged medical equipment, additional lighting and heating, building ventilation and air conditioning can be provided. If existing capacity is insufficient, investigate if it is possible to route additional power from additional locations/transformers around the site or from adjacent sites.
* Safety: The existing electrical distribution network must be able to supply the required equipment load. If this is insufficient/appears unreliable, identify how this can be supported.
* Resilience: Evaluate back-up power and a UPS capacity against essential services demand. If existing capacity is not sufficient, source and establish temporary service capacity.

=== Temporary service zones ===
*Identify locations for temporary service zones where equipment can be located.
*Ensure that equipment and maintenance access is safe and easy.
*Ensure that all distribution boards, circuit breakers and cables are clearly labelled.
=== Services in each bay ===
*Provide pre-wired power strips/trunking as per bay requirements.
*Check that these include sufficient electrical outlets and service points for envisaged equipment.
*Ensure that trunking will carry required equipment loadings. The IUSS Building Engineering Services Guide can be used to check requirements<ref name = "IUSSBES"/>.

[[File:Layout_of_power_in_a_temporary_installation.png|600px|thumb|none|Layout of power in a temporary installation <ref name="BDP2020"/>]]
----

=== Water ===
Water points are needed for handwashing, showers and cleaning. The following issues need to be taken into account.
==== Supply ====
Onsite cold water storage, dedicated to the domestic water requirements of the facility, should be provided. A minimum usable volume of 500 litres per bed should be available.
Hot water storage and consumption should be confirmed by an engineer, as follows:
*Storage 25 L per bed.
*Consumption 180 L/bed.day W/O laundry; 250L /bed. day W laundry.

==== Handwashing ====
See infection control for clinical wash-hand basins
==== Showers ====
Showers for staff coming off shift should be available. Staff flow routes exiting contaminated treatment areas should pass through gowning and shower areas.
----

=== Medical gases, oxygen and vacuum (suction) ===
Medical gases, oxygen and vacuum services will be required in the facility. Mobile gas supply requires piping between supply and patient and clutter floor space. Preferably used fixed installations for patient rooms/cubicles, if possible.

System capacity and point of use pressures and consumption rates are to be ensured at all points. WHO provides technical guidance on [https://www.who.int/publications-detail/oxygen-sources-and-distribution-for-covid-19-treatment-centres oxygen sources and distribution]. 
[[File:Medical gas service layout.png|6oopx|thumb|Medical gas service layout<ref name="BDP2020"/>]]
The following points should also be taken into account.
* For centrally supplied medical gas and vacuum services, system resilience and availability must be ensured.
* Compressors, tanks, accumulators, VIEs, headers and controllers must be secured from uncontrolled access.
* Where possible, gas piping should be reticulated below floors or in ceilings to ensure protection from tampering, damage and ease of access.
* Where reticulation is within open areas, high-level reticulation with point-of-use droppers is advised. Low-level reticulation within rooms is to be avoided.
* Flexible piping can be used, ensuring it does not present a contamination or fire risk and should comply with local regulations. Special care should be taken with flexible O2 piping, keeping it to a minimum.
* Vacuum piping may be contaminated, where point-of-use filtration and collection systems fail. Precautions should be taken when demounting or disconnecting temporary vacuum lines.
* Ensure that oxygen pipelines are designed to provide sufficient flow to all oxygen points in the facility. In terms of utilities, oxygen and medical air would be required. A temporary vacuum point can be provided by mobile medical vacuum units distributed throughout the unit.
* Mobile medical air supplies should be considered where reaching piped specifications are not feasible. Where flexible hoses are used for oxygen and medical air special precautions need to be taken. Flexible oxygen piping must be chemically safe for O2 use. Where perishable flexible piping is used for medical air, terminal filtration at the point-of-use may be required at point-of-use. Especially for long-term use.
* Electrical and gas services can be reticulated against pipe racks or boards fixed to the bed-heads for head to head bed arrangements.
* Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.
* Gas service outlets to be labelled and colour-coded with 3mm lettering.
* SANS 7396-1 should be used to specify the requirements from design to commissioning of medical gas and vacuum systems.
* Medical gas and vacuum pipelines shall be marked per SANS 7396-1 and ISO 5359, as applicable.
* Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.
* SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.
* Plain-ended copper tubing for low-pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.
* Laboratory gas taps and valves shall be marked as described in SANS 10140-4.

=== Lighting ===
Existing lighting systems may need to be modified to suit the clinical requirements in the facility. High bay lighting presents inadequate colour rendering quality for the accurate detection or easy diagnosis of certain clinical conditions. This needs to be evaluated in the selection of supplementary lighting systems.
*Lighting levels should be provided in line with the indoor lighting levels recommended in the Table 6 of IUSS Building Engineering Services .
*Mobile task lighting systems may be adopted in the serious and critical stay wards to supplement incorrect lighting quality.
*Emergency lighting and illuminated emergency egress signage should be linked to the back-up power system.
*External security lighting in external parking areas and spaces around the building should be enhanced to ensure the security of medical staff who need to change shifts at night.

=== Fire safety ===
A functional fire alarm system should be available to support the patient care setting. Fire is a very real threat due to the possibility of an oxygen-enriched atmosphere developing so ventilation is crucial.
The use of temporary facilities for medical care should note the following fire risks (NHS, 2020):
*Patients may have a very high dependency.
*Areas are not specifically designed for patients and do not meet guidance on fire compartmentation and progressive horizontal evacuation.
*Large numbers of patients supplied with oxygen up to 10 litres per minute.
*Possibility of oxygen concentrations exceeding those generally found in the atmosphere- less risk if effective ventilation or large volume i.e. high ceilings.
* Possibility of storage, in excess of 40 litres, of alcohol-based chemicals (such as hand-rub), necessitating a flammables cabinet on site.
*Staff who may not normally work together .
*Staff who may not be familiar with the area.
*Staff not trained in fire safety, progressive horizontal evacuation or oxygen isolation for the specific area.
These factors should be taken into account in fire risk assessments which should then address significant findings in an action plan. Fire assessments should be undertaken by a qualified person and shared with operations and building management staff within the facility. Measures developed should include:
*An automatic fire detection system
*An emergency egress plans are prepared that include patients who have a very high dependency.
*Signage, notices and lighting are installed and are working effectively.
*Management processes are in place to minimise the risk of fire from ignition sources, fuels and oxygen.
*Staff are trained and a fire safety guide sheet for staff is developed and issued.
*Emergency egress routes are kept clear.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Additional Resources''' ==
=== [[Directory of Service Providers|A Directory of Service Providers can be viewed here]] ===

=='''References'''==
<references />

[[Category:COVID-19| ]]
[[Category:Alternate Care Sites|Alternate Care Sites]]

----
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19|(Return to Top)]] 
----

Infrastructure Guidance for COVID-19/Alternate Care Sites

2020-05-08T08:50:10Z

Peta: /* General transmission mitigation */

[[Infrastructure Guidance for COVID-19|Return to Infrastructure Guidance for COVID-19]] 

== '''Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19'''==

This guidance work was initiated under the project titled: 
''Reducing Nosocomial and Community-Acquired Tuberculosis by Strengthening the Capacity of the South African Department of Health to Improve Implementation of Infection Control and Waste Management at All Levels of the Health System Under the President's Emergency Plan for AIDS Relief (PEPFAR)'' 

== '''Introduction''' ==
=== Purpose and approach ===
The global pandemic of COVID-19 caused by the coronavirus, SARS-CoV-2 is likely to result in a surge in need for medical care for Severe Acute Respiratory Syndrome (SARS) in South Africa. Considering the course of the pandemic in other countries, it is anticipated that South African hospitals will not have sufficient capacity to cope with the surge of persons requiring medical attention and that surge capacity via alternate care sites (ACS) will need to be established.
Surge capacity, contemplated here is not the frequent emergency department overcrowding experienced by healthcare facilities (e.g. Friday/Saturday night emergencies) or local casualty emergency that might overcrowd nearby facilities and have little to no impact on the overall healthcare delivery system. It is when a catastrophic event occurs and the affected population seek medical care from existing local healthcare facilities, causing healthcare infrastructure to become exhausted due to excess in demand. During a healthcare surge, the standard of care will shift from focusing on patient-based outcomes to population-based outcomes, and providers should anticipate “a shift to providing care and allocating scarce equipment, supplies and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals.”<ref>[https://asprtracie.hhs.gov/technical-resources/resource/491/altered-standards-of-care-in-mass-casualty-events Health Systems Research Inc., 2005]</ref> 

Surge capacity can be temporarily established in non-traditional environments, such as hotels, exhibition halls, community halls, and as field hospitals, on open spaces. 

In the context of this document, a quarantine site is a facility for patients who do not require continuous professional medical care, while an ACS is defined as a temporary facility that can provide continuous medical care for SARS. This document provides principles and considerations, high-level guidance for minimum requirements and examples for ACS. 

While an extensive set of health facility guidelines does exist<ref>[https://www.iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-servi IUSS Building Engineering Services (2017)]</ref>, these are applicable for conventional facilities and thus include services and guidelines that are not necessarily relevant to the treatment of a novel, highly infectious pathogen, with pandemic effects. Moreover, these do not provide well for the rapid and temporary establishment of facilities. 

In order to formulate high-level guidance, [[as invited by Business for South Africa]], the team reached out to professional industry bodies for inputs, in particular the South African Institute for Architects (SAIA), The Gauteng Institute for Architects (GiFA) [https://www.gifa.org.za/ Gauteng Institute for Architecture] and the [http://www.safhe.co.za/ South African Federation of Hospital Engineering (SAFHE)], by inviting input via a 36-hour research charrette. Relevant historical and contemporary literature was consulted, precedents identified and critically reviewed. An interaction with the team at Wuhan responsible for makeshift hospitals and emergency infectious diseases hospitals, Central-South Architectural Design Institute, was arranged with assistance of the Chinese Embassy. Material from the [[Infrastructure Unit System Support|Infrastructure Unit System Support (IUSS)]], international literature and guidance and input gathered from the broader architectural, engineering and healthcare professional communities was synthesised and moderated by the CSIR team. The draft was reviewed by an expert review panel. 
=== Acknowledgement of contribution ===
The contributions to the initial version of this were gratefully received. [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Acknowledgements|A list of these contributors can be viewed here.]]. 
New contributions are eagerly encouraged along with debate and discussion on the [[Talk:Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites|'''discussion forum.''']] tab above.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Scope and Assumptions''' ==
ACSs as discussed in this document are dedicated, temporary facilities for triage, testing, diagnosis, further referral and treatment of persons:
*suspected of having contracted SARS-CoV-2, (persons under investigation (PUIs)), who are symptomatic and/or are awaiting results,
*or are confirmed to be infected.
ACS will accommodate a variety of clinical, logistical, support and auxiliary services associated with the render of care. ACS will currently not be licensed to provide healthcare services. Since the ACS will operate in a non-healthcare facility, it cannot fully replace a hospital setting and its prime objective is to manage the patient load until the local healthcare system can meet demands. 

=== Exclusions ===
Quarantine facilities are accommodation facilities where a member of the community can remain for the duration of their isolation period. This is typically temporary housing for a cohort of people who do not need intensive medical attention but who cannot stay at home. Patients can take care of themselves and need limited monitoring by medical staff. Quarantine: Containing presumptive-case patients from each other and the general population.
Quarantine facilities – that is for asymptomatic persons who are in the community in self- or imposed isolation, but not displaying symptoms, or who are symptomatic, but are able to safely recover without clinical intervention and do not need continuous medical observation are not considered in this document.

=== Service regime ===
The following assumptions are made with respect to services under consideration.
* Temporary - limited to the part of the pandemic when the “conventional” hospital platform cannot meet demand. To be dismantled, thereafter.
* Uncomplicated, dedicated COVID-19 care is to be prioritised for ACS.
* Patients with comorbidities, paediatrics will be prioritised for conventional facilities, and only accommodated in ACS as a matter of last resort.
* 24 hour, 7 days a week operations. 

=== Assumed mechanism of transmission ===
Transmission of SARS-CoV-2 is understood to be from person to person firstly by [https://en.wikipedia.org/wiki/Transmission_(medicine)#Droplet_infection droplet] transmission, then by the [https://en.wikipedia.org/wiki/Transmission_(medicine)#Direct_contact contact] route and finally via airborne [https://en.wikipedia.org/wiki/Transmission_(medicine)#Airborne_airborne transmission] during or following mechanical aerosolisation. Water transmission risks are minor, occurring in special [https://en.wikipedia.org/wiki/Transmission_(medicine)#Fecal%E2%80%93oral Fecal-oral] circumstances. Reclassification of transmission mechanisms may nullify some of the approaches presented in this guidance. 

=== A call for strategic coordination ===
This document focusses on infrastructure requirements. These provisions are meaningless without staffing, equipping and resourcing. Whilst staffing, equipping and resourcing are not the focus of this document, these are likely to emerge as key constraining features. Resource constraints are likely to become acute during this pandemic. Doctors and nurses are already in critical short supply in South Africa and internationally, and are themselves susceptible to COVID-19 infection. Equipment and consumables are in short supply with heightened global demand, reduced manufacturing capacity and limits in trade flows. This necessitates strategic coordination, proactive planning, options appraisal and prioritisation. 

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Status Quo''' ==
=== Rationale and transmission status ===
According to the [https://en.wikipedia.org/wiki/World_Health_Organization World Health Organisation] (WHO), based on the largest cohort of COVID-19 patients, about 40% of patients with COVID-19 may have mild disease, where treatment is mostly symptomatic and does not require inpatient care. About 40% of patients have moderate disease that may require inpatient care; 15% of patients will have severe disease that requires oxygen therapy or other inpatient interventions, and about 5% have critical disease that requires the patient to receive mechanical ventilation. However, the evolution of the outbreak in some countries has shown a higher proportion of severe and critical cases and the need to rapidly increase surge capacity to prevent rapid exhaustion of biomedical supplies and staff. In some countries, doubling rates of cases every three days has been observed<ref>WHO-2019-nCoV-HCF_operations-2020, [https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf]</ref> 

South Africa has a high burden of disease, with a high prevalence of [https://en.wikipedia.org/wiki/HIV/AIDS_in_South_Africa HIV and TB]. Although evidence is yet to emerge of the effect of SARS-CoV-2 on a population with these pre-existing conditions, there is reason to proceed with caution<ref>The Conversation 2020, https://theconversation.com/tb-hiv-and-COVID-19-urgent-questions-as-three-epidemics-collide-134554</ref>. There is a potential direct and indirect benefit of ACS to people living with HIV and TB, as well as to general public health and the health system preservation. 

With the travel lockdown in place, and continued transmission, it appears that South Africa is on the cusp between cluster transmission and community transmission according to WHO’s classification, shown in the [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites#Key_clinical_and_infection_control_activities_for_different_transmission_scenarios_.5B3.5D|table below]], indicating that preparation should include temporary hospital facilities and mass critical care.

==== Key clinical and infection control activities for different transmission scenarios <ref>WHO 2020, [https://apps.who.int/iris/handle/10665/331492 https://apps.who.int/iris/handle/10665/331492]</ref> ====
{| class="wikitable"
|-
! !! '''No Case''' !! '''Sporadic Case''' !! '''Clusters of Cases''' !! '''Community Transmission'''
|-
| Faculty Space, Including for Transmission|| Usual Space. Enhanced Screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards). || More patient care areas re-purposed for COVID-19 within the health system, especially for severe cases || Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Staff|| Usual space. Enhanced screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards)||More patient care areas repurposed for COVID-19 within the health system, especially for severe cases||Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Supplies||
*On-hand supplies. Equip wards for COVID-19 treatment.
*Identify essential equipment and supplies, including oxygen.
*Prepare expanded local supply chain
||
*Expanded inventory of supplies with detailed protocols for use.
*Activate expanded local supply chain.
*Prepare national supply chain.
||
*Conservation, adaptation, selected re-use when safe.
*Activate contingency planning and procurement for essential equipment and supplies.
*National supply chain.
*Prepare expanded supply chain at the global level
||
*Activate contingency planning should critical equipment be in short supply.
*Determine allocation of lifesaving resources for HCWs and patients.
*Activate expanded global supply chain
|-
| Standard of Care|| Usual care with enhanced awareness and recognition of immediate needs for first COVID-19 patients|| Usual care and treatment for all patients, including those with COVID-19||Identify context-relevant core services. Shift service delivery platforms. Consider reduction in elective patient encounters, including elective surgical procedures.|| Mass critical care (e.g. open ICU for cohorted patients).
|-
| Care areas expansion|| No requirements for expansion|| Designate 10 beds per suspected COVID-19 case|| Expand COVID-19 patient care areas by a factor of 35 ||Expand COVID-19 patient care areas by a factor of 58
|}

=== Quantification of need ===
At this time there are various parallel initiatives aimed at forecasting the South African epidemic, quantifying the projected need for facilities, and a shortfall in existing capacity. At this time, there is no consensus on this. This section will be updated as further data becomes available.
ACS will prioritise mild to moderately affected COVID-19 patients where basic, targeted medical care will be provided. Should patients’ needs evolve, requiring escalation of care, then the transfer of patients from ACS sites to conventional sites of care will be needed as a matter of course, bringing with it logistical challenges and risks. In the event that the conventional hospital platform is unable to cope, ACS will have pressure to provide care for severe and critical patients, and finally for patients with comorbidity and special requirements, such as paediatrics, persons living with HIV (PLHIV), TB patients and pregnant women. The following pragmatic approach, aligned with the WHO recommended strategic approach, is suggested.
*ACS should preferably be identified with space for expansion.
*The set-up should be done so that levels of care can be upgraded to higher levels of uncomplicated care.
*A secondary upgrade for more diverse package of care may become necessary.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Strategic Approach''' ==
According to WHO, clinical interventions must be put into place immediately and then scaled up according to the epidemiologic profile.
[[File:COVID-19 Resource allocation.png|none|thumb|600px|right|WHO Strategic approach to clinical care]] 
Under this declared state of disaster, the clinical care strategy which cannot be accommodated within existing facilities, can, on a temporary basis be hosted in ACS:
*Within and around existing healthcare facilities, via reconfiguration and/or augmentation.
*In existing non-healthcare buildings suitable for repurposing, such as universities, hotels and conference centres, warehouses, gyms, hostels etc.
*On open fields, including paved parking areas with rapidly constructed, dismountable structures, such as modular tented structures or using rapid modular construction techniques. 

ACS will provide isolation, general (non-acute) care for patients with mild to moderate symptoms and as required, acute care for patients with severe symptoms. Containing confirmed-case patients from general population. Confirmed-case patients can be housed together en masse, while presumptive-case patients must be individually quarantined.
As shown in the WHO Strategic approach to clinical care, the WHO recommends a range of services to meet patient need (''Citation needed''). General (non-acute) care ACS model is designed for minimal acuity patients requiring minimal activities of daily living support (e.g. COVID-positive with minimal symptoms or require <2L of oxygen). Acute care ACS model is designed for higher acuity patients requiring closer monitoring or respiratory support (e.g. COVID-positive with pneumonia or respiratory distress requiring ventilator support). Paediatric patients are to be accommodated in separate wards, where strictly controlled visitation may be allowed. 
As a preliminary estimate, the following ratios of service is proposed:
[[File:COVID Ratios of Service.png|none|thumb|600px|center|COVID Ratios of Service]]

{| class="wikitable"
|-
! '''Case severity, risk factors<ref group="Notes"> Test suspect COVID-19 cases according to diagnostic strategy</ref><ref group="Note"> Known risk factors for severe COVID-19: age over 60 years, hypertension, diabetes, cardiovascular disease, chronic respiratory disease, immunocompromising conditions.</ref>''' !! '''Recommendations'''
|-
|Mild || Patient should be instructed to self-isolate and contact COVID-19 information line for advice on testing
and referral.
|-
|Moderate, with no risk factors ||Test suspected COVID-19 cases according to diagnostic strategy. Isolation/ cohorting in:
* Health facilities, if resources allow;
* Community facilities (e.g. stadiums, gymnasiums, hotels) with access to rapid health advice
(i.e. adjacent COVID-19 designated health post/EMT-type 1, telemedicine)
*Self-isolation at home according to National guidance
|-
| Moderate, with risk factors || Patient should be instructed to self-isolate and call COVID-19 hotline for emergency referral as soon as possible
|-
|Severe || Hospitalization for isolation (or cohorting) and inpatient treatment.
|-
|Critical|| Hospitalization for isolation (or cohorting) and inpatient treatment.
|}

=== Notes and References: ===

<references group = "Note" />
<references />

=== Typology dictates & case studies ===

[[File:NHS Nightingale Hospital London.png|thumb|NHS Nightingale Hospital London <ref name="NHS Nightingale Hospital London">Coronavirus: Building NHS Nightingale Hospital London, 2020 [https://www.bbc.com/news/in-pictures-52092253 https://www.bbc.com/news]</ref>, ]]
To meet the requirements set out in this guidance, prospective “host” sites should be carefully evaluated. The type of “host” site selected will strongly influence or dictate the choice of ACS service model.

No site is likely to meet all requirements and recommendations set out in this document. Adaptations and compromises will be necessary. Services should be provided on site where it is pragmatic to do so, for example where similar services are provided. Outsourcing can also be practical/feasible for some services, such as laboratory services, catering and laundry, provided suitable logistical arrangements can be made.

Some typological responses and service models are set out in precedent examples, shown below. The examples demonstrate that a variety of host settings are workable, provided that the appropriate utility can be contrived.

=== Pragmatic approach ===
Other than in metropolitan areas, co-location of ACS on the premises of, or adjacent to existing healthcare facilities will often be preferable because this is where intensivists and specialist clinical staffing will be available, and support services may be well established. Nevertheless, augmenting capacity at existing facilities should take into account current workloads and capacity to ensure that the COVID-19 surge disrupts normal service provision as little as possible, including continuity of care for patients with chronic conditions and TB and HIV patients. 

*'''[[Infrastructure Guidance for COVID-19/Alternate Care Sites/Case Studies|SARS ACS Precedents and Case Studies can be found here]] '''

=== Notes and References ===
<references />

== '''ACS Infrastructure Planning''' ==

=== Establishing a team ===
A planning team should be formalised to establish the minimum planning and operational requirements for the ACS and to liaise with the local community. The team should include individuals with expertise in the following areas (ideally with knowledge of healthcare delivery under emergency conditions):
*Disaster response / emergency management coordination,
*Clinical care and staffing,
*Infection Prevention and Control practitioners must be involved in all stages of planning, commissioning, in-use, and decommissioning of the facility
*Facility set-up, operations and management,
*Security,
*Transport (patient, staff),
*Engineering and project management,
*Procurement and coordination of supplies, equipment and pharmaceuticals, and
*Community liaison to ensure that concerns of the adjacent population on understood an addressed.
It is important to ensure compliance with health, safety and building regulations, by ensuring the involvement of relevant local authorities. Stakeholder engagement should be formally documented. Concerns and grievances should be systematically addressed.

=== Structural integrity and operational responsibility ===

'''Structural modifications:''' ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered. 

'''Competent person:''' All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed. 

'''Asset responsibility:''' Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented. 

'''Integrity and responsibility'''

'''Structural modifications''': ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered.

'''Competent person''': All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed.

'''Asset responsibility''': Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented.

'''Decommissioning''': Decommissioning of the facility shall be assigned to the competent person discussed above. All residual structures upon decommissioning shall comply with the National Building Regulations. Upon decommissioning, removal of equipment shall be the responsibility of the owner. An infection prevention and control practitioner should be engaged in the decommissioning phase to oversee terminal cleaning and disinfection of equipment and premises.

'''Closure''': Once all patients can be safely discharged or transported back to existing facilities for continued care and there are no ongoing healthcare surge capacity needs, the ACS can be closed. Shut down of an ACS will require decommissioning, identification of new homes or storage for equipment, and termination of ongoing contracts or arrangements. Shut down should be expedited so that the facility can quickly be returned to the control of the existing owners and returned to its usual function.

Action checklist items for ACS closure should include, but not be limited to, the following:
*conduct a site walk-through with the facility owner when shutdown activities are completed to ensure that terminal cleaning and disinfection of supplies and premises, removal of equipment and supplies, and other surge closure activities have been completed to the owner’s satisfaction.
*perform medical records storage procedures.

== '''Site Selection''' ==
When selecting a site, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital can be utilised to determine whether the site is suitable for a 100, 1000 or 2000 bed facility, as required. The following indicative minimum site sizes are needed:
*100 Bed ACS/ hospital conversion, requires ± 4 300 m2
*1000 Bed ACS/ hospital conversion, requires ± 17 600 m2
Evaluation should be done by examining plans (if available), satellite images, drone images, scans and by physical inspection (walkabout). A comprehensive photographic survey should be undertaken and retained for record purposes on the site inspection. This will serve as an audit record and may assist in returning the site to its original function on ACS decommissioning and closure. When scrutinising documents and conducting site inspections to confirm the suitability of a site to host an ACS, the following criteria should be taken into account.
=== Criteria ===
*Affordability (costs, including operational costs known and budget identified),
*Sufficient physical space and capacity to house the immediate need, with the potential to accommodate physical space requirements. For example, open site should not be sloping,
*Legal rights and encumbrances, including renewal opportunity,
*Good access to highway and main roads,
*Well secured perimeter and limited controlled access points,
*Proximity to other hospitals and care sites,
*Accessibility for key staff and public transport,
*Good vehicular access around the site to set up temporary equipment such as back-up generators,
*Free from clear and present danger,
*Outside attenuation zones, floodplains,
*Outside high wind zones,
*Structure in good repair,
*Effective onsite facilities management team who understand how systems work,
*Potential for expansion, if required,
*Access to sufficient capacity for
**potable water,
**adequate sewage,
**telephone,
**internet access with sufficient bandwidth,
**electricity,
*A zone for cleaning, disinfection, and decontamination of equipment at least 15 metres away from occupied areas with access to water, a hard impervious surface and drying areas in the sun, with runoff discharge into the sewer and not into marine ecosystems or the environment. Include area for cleaning and storage of cleaning equipment.
*Likelihood of acceptance of hosting an ACS by the adjacent and local community

=== Desirable ===
*Durable, cleanable surfaces,
*Large open spaces that can be converted to accommodate temporary structures,
*Good ventilation,
*On-site kitchen and laundry,
*Housekeeping staff (chemical and equipment storage, lockers, rest facility, administration office),
*Space conducive for staff respite area and locker rooms,
*Amenities with universal access,
*Fire protection safety and equipment,
*Elevator access for patients if the building has more than one floor,
*Capacity for expansion, and
*Accessible to at least two roadways to provide continued access in the event that one roadway becomes blocked on inaccessible.

== '''Infection Prevention and Control''' ==
General guidance for COVID-19 [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|Infection Prevention and Control]] can be accessed [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|here]] 

Infection prevention and control in the context of COVID-19 should respond to transmission routes of primary concern for the pathogen of interest (droplet and contact transmission, and management of risk waste) as well as infection risk of a general nature (water and sewerage, airborne transmission – under high TB/HIV burden, and general waste).
In addition to satisfying [https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html standard precautions for all patient care], transmission-based precautions should focus on three pillars: exposure reduction by spatial configuration, operational strategies, and personal protection.
=== Transmission-based precautions ===
'''Droplet and contact spread''': Transmission of SARS-CoV-2 virus occurs via droplet and contact spread. The virus has been shown to persist on surfaces for extended periods of time and is known to be efficient at infecting people. 

'''Medical waste and linen:''' As SARS-CoV-02 is carried in body fluids and faecal matter, disposal of contaminated items (tissues) and cleaning regimes (spaces, garments, linen) should be accommodated carefully in the workflow design and infrastructure provision. A site-specific waste management plan should be formulated in accordance with a site-specific waste management plan with reference to SANS 10248. 

'''Airborne transmission:''' Under exceptional circumstances, the risk of airborne transmission arises for SARS-CoV-2, as detailed below.
{| class="wikitable"
|-
!Airborne Transmission Risk Factors
|-
|
As SARS-CoV-2 is not considered airborne, respiratory protection against airborne transmission is not considered necessary, except where aerosolisation of particles may be a risk.
According to the CDC
*tracheal intubation,
*non-invasive ventilation,
*tracheotomy,
*cardiopulmonary resuscitation, or
*manual ventilation before intubation and bronchoscopy.
According to doctors in the field also when performing
*COVID-19 diagnostic sampling as patients can be induced to cough and sneeze.
*Suspected or confirmed comorbidity of TB is not an additional risk where correct COVID-19 PPE is applied.

|}
South Africa has a high prevalence of TB and HIV, and therefore, although the risk of COVID-19 transmission via the airborne route is not paramount, there is a high likelihood that undiagnosed TB infectious patients may present at the ACS for treatment. TB triage may be challenging in the ACS as there are symptoms in common (coughing) with COVID-19. This country-specific risk is taken into account in this guidance

=== Additional precautions ===
'''Water and sewerage contamination:''' The International Water Association [[Infrastructure Guidance for COVID-19/Alternate Care Sites/COVID-19 A Water Professionals Perspective|concluded]] that water and sewerage contamination is not considered to be a key risk factor for COVID-19. The panel expressed concern for “how waste and specifically wastewater (medical) would be handled by places (e.g., hostels, hotels) that are used to serve as interim COVID-19 quarantine or testing facilities or accommodation ([ACS]. These are places other than hospitals that are used in the interim for such purposes and do not usually handle wastewater from medical settings. Such facilities should be monitored carefully.” 

== '''Spatial Strategies for Infection Prevention and Control''' ==

=== Restricted access and zone control ===
The site will be arranged to establish clear zoning, with a clear restricted zone protocol and access protection. Zones should be deemed to be "contaminated" or "uncontaminated" with clear transition areas between them.

; Contaminated zones
: (also known as "dirty areas") are areas occupied by COVID-19 infected persons, PUIs, equipment, materials and supplies which have come into contact with such persons without yet undergoing a decontamination procedure. These areas will include patient ward areas and ablutions, patient admissions (including ambulance drop-off) and the associated clinical areas. Staff rest and dining facilities should be outside the contaminated zone. Limited stock for immediate use should be kept in the contaminated zone. Layout designs should consolidate contaminated zones as far as reasonable, and avoid uncontaminated zones as islands in contaminated zones.

; Uncontaminated zones
: (also known as "clean areas") are areas not generally occupied by PUIs or confirmed COVID-19 infected persons. Equipment, materials and supplies in these areas have not yet come into contact with contaminated zones or have undergone a decontamination procedure. These will include clinical management planning rooms, stock rooms, bulk stores, pharmacy, laboratory areas, kitchen and laundry.

; Transition zones
: (also known as intermediate zone) are the spaces through which transfer of people and goods from uncontaminated to decontaminated zones, and vice versa, occur. Materials from the contaminated zone should be decontaminated or contained in the transition zone. The transfer of goods and persons should be highly ritualised and, as far as possible, traffic across transition zones should be minimised. Transition areas should be strategically located to serve this function. Separation of in-going and out-going transfer of goods and persons is preferable. Transition areas include ambulance, trolley decontamination, CSSD, laundry and waste bagging areas, patient locker area and staff change areas with spaces for donning and doffing of PPE.

=== Site layout and master-planning ===
Spatial configuration and layout can ensure unnecessary cross-over of function is avoided. This entails the systematic separation of functions and the managed transition between activities to facilitate consistency of care, an orderly, efficient work environment, less waste and reduced risk for improved outcomes. To achieve this, functional relationships should first be considered at the site level before being considered at the building level. 

<gallery mode=packed heights=300px style="text-align:left">
Layout for a SARS facility, clustering functions with minimised cross-over.png|center|thumb|Layout for a SARS facility, clustering functions with minimised cross-over <ref name="Layout1">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Layout_for_a_Patient_cohorting_strategy.png|center|thumb|Layout for a Patient cohorting strategy <ref name="Layout3">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Tygerberg Hospital virus triage unit site layout.png|center|thumb|Tygerberg Hospital virus triage unit site layout <ref name="Western Cape Provincial Government, 2020a">Western Cape Provincial Government, 2020 a</ref>
</gallery>

The WHO's Clustering Layout <ref name="Layout1"/> and Tygerberg Hospital virus triage unit<ref name="Western Cape Provincial Government, 2020a"/> show worked examples of building and site layouts, which are configured with these principles, respectively. '''Cohorting''' is defined as clustering patients with similar or compatible clinical needs together for risk reduction, acuity, efficiency and quality management, as illustrated in WHO's Cohorting Layout <ref name="Layout3"/>

=== Workflow ===
Within individual functional zones, the workflow activities can be arranged to proceed from clean procedures to contaminated procedures. In the example below, the staff arrival, PPE donning, doffing and patient flows are worked to have controlled interaction and minimised cross-over

<gallery mode=packed heights=400px >
ACS HCW Flow.png |ACS Health Care Worker Flow
COVID-19 Workflow in small unit.png |COVID-19 Workflow in Small Testing Unit <ref name="Western Cape Provincial Government, 2020b>Western Cape Provincial Government, 2020 b</ref>
COVID-19 Workflow in large unit.png |COVID-19 Workflow in Large Testing Unit <ref name="Western Cape Provincial Government, 2020b"/>
</gallery>

As far as possible, a single direction flow of clean to dirty is recommended for all processes: support services, supply and waste.
The Small ACS unit workflow diagram<ref name="Western Cape Provincial Government, 2020b"/> illustrates the recommended separation of access and exit, separate waiting seats, for persons who may be COVID-19 infected. Separate spaces are provided for donning and doffing PPE. Staff change areas are provided.

In the Large ACS unit workflow diagram <ref name="Western Cape Provincial Government, 2020b"/>, there is a clear separation between staff areas and patient areas. Waiting seats are set far apart to reduce transmission risk. Staff change rooms are provided near the point of entry to the facility for staff to change from street clothes into medical work clothes. To prevent work clothes worn inside the facility from contaminating street clothes, these are kept in separate lockers. A step-over barrier from dirty to clean sides of the change room is helpful to enforce a mind-set of avoiding cross-contamination. Bins for contaminated garments are to be provided in change rooms. Shower facilities are to be provided for staff.

== '''Operational Strategies''' ==
=== Cleaning, disinfection and decontamination ===
Surface and substrate specification, and detailing of all areas should, as far as possible, allow for frequent:
*Cleaning with detergent and water.
*Disinfection with 75% alcohol solution (metal surfaces).
*[https://en.wikipedia.org/wiki/Sodium_hypochlorite Sodium hypochlorite] (1,000 ppm)/ Household bleach.
*Disinfectants listed on the EPA List N<ref>The United States Environmental Protection Agency, [https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 List N: Disinfectants for Use Against SARS-CoV-2 (Last Visited 2020) ]</ref> (for non-critical environmental cleaning).
*High-intensity ultraviolet surface disinfection (UV-C).
*Decontamination and sterilisation of clinical equipment.

=== Goods and waste management ===
Remove any unnecessary furniture, equipment and paraphernalia from all patient care and clinical areas. Provide a clear, secure space for waste management. Any potentially infectious waste materials generated at the ACS should be considered and treated as medical waste (health care risk waste). The applicable legislation is:
*[https://www.gov.za/sites/default/files/gcis_document/201409/35405gen452.pdf The National and Provincial Health Care Risk Waste Management Regulations].
*[https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf National Department of Health COVID-19 Environmental Health Guidelines.]<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>
Waste disposal bins should be positioned near the exit inside each patient rooms or wards to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another patient in the same room.

=== Materials and finishes ===
Floor materials must be:
*Level,
*Free of dust and oil,
*Impervious and smooth,
*Slip-resistant in wet areas (e.g. patient ablutions).
Smooth, cement screed floors are acceptable. Where hosting facilities have carpeted areas, a risk assessment of factors such as durability, hygiene and decontamination needs to be conducted. In cases where the acceptance of carpeted flooring is contradicted (but other factors make it a compelling option), temporary floor finishes or covering can be investigated.

== '''Personal Protection''' ==
=== Hand sanitation ===
Where wash-hand basins are not provided, clinical wash-hand basins should be installed, at the minimum rate of provision of one wash-hand basin per 5 beds. Clinical wash-hand basins (see figure below) have a variety of features not present in standard wash-hand basins, which are preferable for infection prevention and control. Where standard wash-hand basins are provided, an upgrade is not necessary. In all cases, there should be no surfaces and no clutter, equipment or supplies in the vicinity of wash-hand basins, including surgical gloves.
<gallery mode=packed heights=400px>
Clinical hand wash basin.png|Handwash Basin <ref>de Jager 2020</ref>
Portable Wash-hand Basin.png|Portable wash hand basins can be provided in ACS <ref name="BDPa">BDP 2020, NHS nightingale instruction manual, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf</ref>
</gallery>

Where wash-hand basins are not available, portable units can be used, as shown above<ref name="BDPa"/>. Mounted brackets for hand sanitisers are to be provided for every two beds, preferably mounted near the foot rather than the head of the bed and at all common touch points such as entry points at ablution facilities, linen room, sluice, storerooms, medicine rooms/cupboards, near refrigerators, telephones, light switches, at entry/exit doors, etc.

=== Personal protective equipment ===
Donning and doffing points for personal protective equipment, and convenient, safe disposal of consumables to be placed at critical key points when entering patient areas.
----

== '''General Transmission Mitigation''' ==
=== Water and sanitation ===
To comply with National Building Regulations; Hazardous Biological Agents Regulations and National Department of Health COVID-19 Environmental Health Guidelines<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>.

=== Droplet aerosolisation ===
When designating areas for procedures during which aerosolization and airborne transmission risk is high, the building ventilation must be carefully considered to take into account downstream risks. In particular, consider to where potentially contaminated air, arising from aerosol-generating procedures, is exhausted. In general, air exhausted directly to the outside is diluted and considered safe, unless there are openings to occupied spaces near the exhaust air outlet. 

In the event that potentially occupied spaces will receive partially diluted or undiluted contaminated air, or where this is indeterminate, the aerosolising activity should be designated to an alternate area. In the event that an alternative is not available, some treatment regime (air filtration or air disinfection) is necessary. 

In most naturally ventilated settings, the airflow direction between zones may fluctuate according to the wind direction. Such high-risk spaces should not be adjacent to spaces with high susceptibility rates, such as PUI areas and uncontaminated areas. Contaminated areas should not be directly adjacent to clean areas unless mechanically ventilated. 
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|Guidance on COVID-19 building ventilation design is provided here]].

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Health, Safety and Well-being''' ==
In addition to the infection prevention and control measures discussed above, the following should be provided for health, safety and well-being.
=== General provisions ===
*Minimised and controlled entry and exit points, with suitable control.
*Clearly identified accessible and marked routes for patients, staff, goods and waste.
*Clear designation of restricted zones.
=== Site level provisions ===
*Safe staff parking and arrival of staff via planned and public transport.
*Clearly demarcated parking for people with disabilities.
*Arrival and departure point for patients via public transport, passenger vehicles, and emergency service.
*Limited safe patient parking.
*Supply of goods and removal of waste.

=== Within and between buildings ===
*Entrances with a clear opening width (CoW) of at least 900mm.
*Routes with a minimum width of 2 000mm free of hazards, for example, rubbish bins.
*All clinical, patient and support areas to be accessible by trolley.
'''Ramps''' should be of stable construction, capable of sustaining a mass of 300kg. They should incorporate side lips and the surface should be slip-resistant. Gradients should be as gentle as the circumstances allow. (Recommended maximum 1:20). 
'''Small changes in floor levels''' are not desirable, but where these exist are to be clearly marked with reflective paint/ tape, and lit at night
Elevators between different floors, where patients need access (The recommended minimum lift size for patient trolley/stretcher movement is 1 400mm × 2 400mm, however, this may not be possible). 
'''Pathways''' to be lit at night, where used at night. 
'''Staircases''' must be well-lit at night with non-slip surfaces and secure balustrades. 
'''Doors''', Double doors and automated or push-operated doors to all clinical areas are to be preferred, where these are newly installed or able to be retrofitted. Door closers are to be disabled, where not necessary to reduce touch surfaces. Hand sanitisers to be provided at where high touch common surfaces occur (e.g. wall-mounted at doorways).

=== Signage ===
The appropriate level of information to facilitate legibility, orientation and wayfinding. Minimum standards, signage to be:
*Clearly visible, simple font, font size, contrasting colours, placed in the field of vision
*Washable
*Comprehensive safety signage - fire signage (exits, equipment etc.)
*Restricted areas clearly marked
*Identification signage - each patient space to be allocated a unique number and a whiteboard or perspex sheet for writing the patient’s name
Signs should be posted immediately outside of patient rooms indicating appropriate IPC precautions and required personal protective equipment (PPE).
Signage of a temporary nature can be provided on laminated white A4 sheets attached eye-level. The text should be black sans-serif (for instance Arial) text at least 40point size and centrally positioned on the sheet. Detailed guidance on signage is provided in IUSS Inclusive environments.
=== Safety and security ===
Upon identification of the ACS host site, a team should be convened to conduct a multidisciplinary safety and security analysis. These critical team members need to form the working committee responsible for undertaking the detailed assessment of the existing facility’s security. They should analyse data about the security system’s condition and review existing security concerns or issues that are reasonably likely to become concerns in the near future. The figure below represents a five-zone approach to security, which is a recommended, systematic approach to security.
[[File:Zonal approach to security.png|center|600px|thumb|IUSS Security- Zonal Approach to Security <ref name="IUSS Security">IUSS Hospital design principles - Security [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file]</ref>]]
The security strategy should take into account that whilst clinical services and some logistical and support services will be required 24 hours a day, seven days per week, some support services, logistics services and auxiliary services may only be operational for the minimum periods required to meet demand. These functional elements should be capable of being secured, for example over weekends and at night, as the case may be.
Detailed guidance is available in [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file IUSS Hospital design principles - Security] <ref name="IUSS Security"/>

=== Comfort and dignity ===
Supplemental heating: Patient health and comfort are dependent on, amongst others, maintaining body temperature. The ACS structural technology must be selected to achieve the general indoor environment conditions discussed in a subsequent section for all clinical and occupied areas. As we are moving into South African winter supplemental heating may be required, especially in the evenings, in order to avoid hypothermia. Use of fans, bar, radiator or gas heaters should be prohibited. Unless clinical areas can be maintained above 18 degrees centigrade, patients should each have an infrared heater available, in addition to blankets. Personal/ donated blankets can be considered if they are laundered first and could be destroyed upon discharge.
Mobile screens should be available to provide privacy where necessary (e.g. during consultations or procedures).
<gallery mode = packed heights = 400px>
Bed_Isolator_-Vietnam.png|thumb|Flexible Barrier Isolator<ref>WHO. (2020), Severe Acute Respiratory Infections Treatment Centre. Geneva, Switzerland : WHO- World Health Organization</ref>
ACS Cohort beds.png|ACS Cohort beds.png|thumb|Excel Centre London 04-2020 <ref>Architects' Journal 2020, [https://www.architectsjournal.co.uk/news/nhs-nightingale-bdp-on-the-first-nine-days-converting-the-excel-centre/10046749.article https://www.architectsjournal.co.uk/news]</ref>
</gallery>
Some solutions which address patient privacy and dignity are depicted above.

=== Notes ===
<references/>

== '''Schedule of Accommodation''' ==
Based on clinical needs of the ACS, a schedule of accommodation can be crafted capturing the clinical, clinical, logistical, support and auxiliary services associated with the render of care. When deriving a schedule of accommodation, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital tool can be used. Functions to be accommodated are: 
'''Clinical services''': Triage, rapid assessment of persons entering the facility, to expeditiously identify and render the appropriate service. Admissions and registration. Inpatient accommodation is to be organised according to cohorting principles, discussed above. Testing and diagnostics, including laboratories and x-ray. Safe storage and dispensing of drugs to patients.Offices for clinical administration and clinical planning meeting rooms in the clean zone are needed. 
'''Logistical services:''' Logistical services will entail management of flows of people, goods, services and information to and from the site, as well as within the site. It includes security and communication arrangements. Staff entry, preparations to transition from outside to clinical work environment, including pause areas for relief. Emergency services, visitors. Goods, supplies and storage and waste removal and/ or treatment.
Support services key to the provision of clinical services should be separated so that the risks associated with that particular activity can be managed. 
'''Support services are:'''
*Laboratory services
*Catering
*Laundry
*Environmental cleaning and housekeeping
*CSSD
*Maintenance and cleaning of surrounds, eg. waste areas
*Porters/”runners”, stretchers/wheelchairs
*Mortuary
* Security
Support services can be provided off-site, in which case, safe, secure and efficient transfer and logistical arrangements should be designed. 
'''Auxiliary services:''' Auxiliary services are services which may be provided on or near the ACS site, but which are not directly related to core clinical care. This included overnight accommodation for staff who may not wish to return home to avoid exposing their families, or who need rest between shifts, or for discharged patients awaiting transport home, volunteers who have recovered from SARS-CoV-2.
Limited psychosocial services and allied health services may also be provided on or near ACS for example by approved partners.
Examples of schedules of accommodation for patient and support spaces for a protective isolation ward is available [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedule for COVID-19 Isolation Wards|here]] and mild to severe cases [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedules for COVID-19 Wards for Mild to Severe Cases|here]].

== '''Clinical Services''' ==
=== Triage ===
Confirmed COVID-19 cases and PUIs who are referred from a testing facility or a higher level of care, will enter the facility in a triage area to receive vital screening and initial assessment. They will be registered and admitted to inpatient care. They will be assigned a "ward" or section of the facility - based on disease status and acuity. These are Protective Isolation, the Mild & Moderate ward, or the Critical & Severe wards. Patients should be clustered according to gender. As far as practicable, ablutions for each gender, isolation patients, paediatrics and staff shall be separately provided. Paediatrics patients, if admitted, are to be assigned a dedicated section.
As patients recover or deteriorate, they may be relocated to the appropriate section/ ward.
Once the patient has sufficiently recovered and a negative test result is received they will be appropriately decontaminated and discharged, collecting medication from the dispensary on exit. Patient movement between various sections of the ACS will be restricted as far as possible, with mobile radiology units, in-ward medication dispensing and in-ward food service.

=== Inpatient ACS accommodation ===
Separate spaces for:
*suspected, unconfirmed cases, under observation (PUIs), to be accommodated in isolation facilities (separate rooms, if possible);
*patients with confirmed COVID-19 with mild to moderate disease, not requiring dedicated oxygen therapy;
*patients who require dedicated oxygen therapy;
*patients requiring mechanical ventilation; and
*recovered/ confirmed negative.
==== Protective Isolation Facilities ====
Suspected, unconfirmed cases, under observation – persons under investigation (PUIs) to be accommodated in protective isolation facilities (separate positive-pressure rooms, if possible). PUI are restricted to their rooms. All food and laundry services will be brought to the PUI rooms to reduce interaction and potential contamination. All waste will be collected by facility staff and taken to waste handling areas. Infection prevention and control measures are put in place for the handling of used food utensil and laundry as well as waste collection. PUI areas will have restricted access, including for staff serving other inpatient sections, for confirmed cases.

==== Inpatients accommodation for confirmed COVID-19 ====

Inpatient facilities confirmed positive COVID-19 can be accommodated in large shared ‘wards’ with partitioning between patients. Partitioning between patients is optional. Partitioning is preferable to curtains found in conventional hospitals, as they are more conducive to daily cleaning. If curtains are used, antimicrobial treated fabrics with biocide used to treat the curtains has been tested to international standard EN 14476 and shown to be effective against H1N1 Influenza A Virus (Swine Flu), >99.999% kill rate in 5 minutes and measles morbillivirus, >99.99% kill rate in 5 minutes are preferred. If only separate rooms are available, patient monitoring and surveillance will need to be accommodated. This phase of treatment has a lower area/space requirement compared with PUIs, as cross-infection between patients is less of a concern. Shared ablution facilities are acceptable. It is recommended that, at least, two general accommodation ward areas be provided. 

a) Mild and moderate patients, and 
b) Serious and critical patients. 

The room must have openable windows for natural ventilation if a dedicated positive pressure ventilation system is not available. Ducted ventilation systems shall not be shared between PUI areas and confirmed COVID-19 patient areas. 
[[File:COVID-19 ACS - protective isolation – bed layout.png|thumb|center|800px|ACS - protective isolation – bed layout]]
[[File:COVID-19 ACS – mild-moderate patient bed layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient bed layout]]
[[File:COVID-19 ACS – mild-moderate patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient shared ward layout]]
[[File:COVID-19 ACS – severe-critical patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – severe-critical patient shared ward layout]]

Examples above show bed layout with bed spacing for protective isolation, a mild/moderate patient and a mild/moderate patient shared ward and for a severe/critical patient

=== Patient services ===
Patients in ACS will not generally be ambulatory and will be confined to their room, or cubicle in a bed. In general, domestic beds or hospitality industry (hotel) beds are not suitable for patient care. These should only be used where a hospital-grade bed cannot be sourced, as hospital beds are designed for ease of cleaning and decontamination (for infection prevention and control) and with patient and ergonomics, safety and comfort taken into account (they prevent back injury for nursing staff and can help to prevent bedsores). The higher the specification of bed, the more suitable it is for the higher levels of care. Lockers for patients personal belongings should be provided in the uncontaminated zone (in which case bedside lockers will not be necessary), and it is preferable (where bedside lockers are not provided) for overbed tables to be provided, per bed, if possible. 
The following beds are suitable:
*Repaired and refurbished beds from condemned hospital stocks.
*South African National Standard, SANS 521:2013 Edition 3.5, on Hospital beds and cots ISBN 978-0-626-28830-3.
*Beds listed on the National Treasury (See [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Hospital Bed Specification|specification]]).
The table below details the minimum services required at each patient bed. Details on these services are discussed in a subsequent section of the document.

{| class="wikitable"
|-
! Service/ Capacity!!Triage!!Isolation !!Mild – moderate inpatient!!Severe case wards!!Critical case wards
|-
| Power – 16A 230V Single socket outlet||As needed ||1 per bed||1 per bed||3 per bed||6 per bed
|-
| UPS Power – 16A 230V Single socket outlet ||As needed||1 per bed||1 per bed||1 per bed||2 per bed
|-
| Medical Air<ref group="Note">Mobile units recommended for intermittent use. 3 per 20 beds</ref><ref group="Note">There are some ventilators which have built-in compressors allowing them to function without Medical Air. This is however, not the norm. With Ventilators probably being the most difficult medical device to obtain at present, it would be prudent to rather allow for Medical Air at each bed.</ref> (LP)400kPa||No||Yes||No||Yes||Yes
|-
| Medical O2 -400kPa||Portable/shared||Portable/shared||No||One||Two
|-
| Vacuum-40kPa||No||Portable/shared||Portable/shared||Yes||Yes
|-
| Equipment rail||||||||Yes||Yes
|-
| Upper room UVGI||Optional||Optional||||||Optional
|-
| Examination light||No||No||Yes||Yes||Yes
|-
| Room Ventilation rate||60 L/s per person||10 L/s per person||10 L/s per person||10 L/s per person||12 ACH
|}
'''Notes: '''
<references group="Note" />

Two additional 16A 230V single socket outlets, one two-pin outlet and a worktop should be provided for every 32 beds (or part thereof), for:
*Electrocardiograph (ECG): Could be omitted if monitors have a full 12 lead ECG function.
*Blood gas analyser: Could be omitted if a Lab Services are available.
*Staff cellphone charging.

Example of healthcare technology to be provided for critical care patients is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]. Severe patients may be provided continuous positive airway pressure (CPAP). Emergency trolleys (“crash carts”) are to be provided in patient areas with convenient access to patient beds, out of the passage of corridors and is moved to the patient when needed. 1 crash cart for every 16 patients (or part thereof, with at least one dedicated for PUIs. An example of provisions for a crash cart is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]
==== Patient ablutions ====
[[SARS-CoV-2 is found in faecal matter]], so careful management of patient body fluids is crucial and convenient, practical support for frequent cleaning of ablutions especially shared ablutions is necessary. Dedicated ablutions (toilets and showers) are to be provided for patient use. Toilets and showers should be in separate rooms.
Hand washbasins and or/ hand sanitiser should be provided both inside and outside the toilet room so that patients can wash their hands on the way in and on the way out of the room.
*1 toilet for every 8 persons.
*1 shower for every 8 persons.
*1 disabled ablution for every 8 regular ablutions (or part thereof).
*1 disabled shower for every 8 persons (or part thereof).

Critical and severe patients may be sedated and have a reduced need to access ablutions, ablution facilities proximity and provision can take this factor into account. Showers and wash hand basins should have hot and cold running water. Where possible ablution facilities must have openable windows for natural ventilation, if not possible the bathroom extraction and room ventilation system must be reviewed before admitting patient '''(see [[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|ventilation]]).'''

Portable toilets and showers may be used, provided that suitable hand wash facilities are provided. These will need to be suitably located, preferably in decentralised clusters, so that patients can easily access them without needing to walk very far. Ablutions should be located and designed in such a way as to provide visual and acoustic privacy, dignity and avoid disturbance of other nearby patients when accessing, using or cleaning the ablutions. Separate ablutions are to be provided for PUIs and confirmed patients.

====Makeshift sluice areas ====
In conventional hospital settings, sluice rooms are provided for cleaning and sanitation of soiled equipment, such as bedpans. In a temporary setting, such as an ACS, the establishment of a temporary sluice room may not be practicable, and there may not be facilities for emptying buckets, rinsing equipment etc.. The following is suggested:
Allocate a toilet, hand wash basin, not in splash range and restrict access to it for draining buckets and install a macerator for disposal of disposable bedpans. Electrical, water and waste supply points required as per supplier specification.
==== Dedicated patient treatment areas ====
The following dedicated, private spaces per ward for clinical procedures are recommended:
*Counselling and consulting room (can be shared), as shown in the figure below
[[File:Consulting room example layout.png|400px|thumb|center|Consulting room example layout]]
*Minor procedures room, as per the example provided in the figure below 
[[File:Treatment-minor procedures room example layout.png|400px|thumb|center|Treatment / minor procedures room example layout]]

== '''Logistical Services''' ==
=== Communications ===
Electronic communication should be facilitated in all zones of the ACS by the provision of device charging stations, and wifi.
=== Visitors entry point ===
Visitors are strongly discouraged from entering the ACS.
*In paediatric wards, one parent may be accommodated to visit a patient. In such cases, direct access for the visitor should be provided so that the visitor does not need to pass through the general patient area. Appropriate PPE must be donned before entering the patient area and hand washing/sanitising must be done when exiting the area.
*Non-patients who are accompanying suspected patients to the facility for testing or admission must be accommodated in a well-ventilated, spacious waiting area. Signage in such waiting areas must inform visitors about symptoms, hand hygiene and PPE.
*Hand washing/sanitizing facilities should be provided.

=== Staff areas ===
==== Staff change rooms ====
A minimum of 9m² or 4m² for a single person, increasing by one m² for each additional person is required. The clean (street side) and dirty (contaminated facility side) of the change room should be separated by a step-over barrier.

==== Staff rest areas ====
Staff rest areas within the main facility should be provided with access to kitchenette facilities and staff ablutions.
=== Staff auxiliary services ===
'''Staff on-call:'''Since staff may be required to work long hours or could be required to be on-call, shared, overnight sleeping facilities can be provided for staff on duty, outside the contaminated area, but in close proximity on the patient areas. An example is set out in the diagram below.
[[File:Example of on-call sleeping area for staff.png|center|600px|thumb|Example of overnight sleeping area for staff]]

'''Staff accommodation:''' It is advisable to provide some staff accommodation for off-duty staff who may not have suitable alternatives, for example homes too far away, transport limitations or the requirement not to expose family members to risk. This should be provided in the vicinity of the ACS, but in a physically separated zone. This amenity can be outsourced.

== '''Support Services''' ==
=== Workflow principle ===
[[File:Linen processing cycle.png|none|thumb|Linen processing cycle <ref>IUSS 2014 [https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department]</ref>]]
Progressive workflow from “dirty” (that is contaminated) to “clean” linen is advisable to reduce the risk of exposure to contaminated materials. The workflow diagram below, showing the progression from the dirty linen receiving area, to the cleaning process, to decontamination and drying, and finally sorting and packing, and storage, illustrates this principle.
=== Laboratory ===
[[File:Example of modular laboratory.png|right|thumb|Example of modular laboratory]]
The WHO recommends the following laboratory diagnostic equipment be accommodated:<ref>WHO 2020, [https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items]</ref>.
<nowiki>• Lab screening test kit
• Lab confirmation test kit
• RT-PCR kit
• Extraction kit
• Cartridges for RT-PCR automatic systems
• Swab and Viral transport medium
</nowiki>
Additional accommodation requirements are:
# Reception counter- receiving specimens
# Testing with perspex/ glass screen
# Receiving/Data capture
# Specimen holding
# Toilet - staff
# Blood storage fridge
Can be provided as a modular laboratory unit as shown in the diagram.
=== Pharmacy ===
The purpose of the pharmacy is to provide medicines needed for inpatient treatment and care.
All medical supplies should be stored in a secure, climate-controlled area in close proximity to the patient treatment area. The pharmacy must have dry, lockable, climate-controlled storage of medications. Most pharmaceuticals are labelled with storage temperatures. The pharmacy should have adequate ventilation through an openable window to prevent humidity from building up in the room. Air-conditioning or mechanical ventilation can be provided, if necessary.

Dispensing areas must be well lit. Worktop in space for stock records and administration. Dispensing counters to have perspex or glass screens to serveries. Social distancing implemented at counter, between pharmacists/assistants and between chairs in waiting area.

Can be provided in a mobile unit.

=== Radiology ===
The purpose of radiology services is to provide chest X-Ray services for COVID-19 diagnostics. In general, CT scans, bucky rooms etc. associated with some radiology equipment require specialised infrastructure and therefore is not suitable for ACS. Radiology services can be provided as a mobile floor standing unit, or containerised unit. Alternative technologies such as Lodox and hand-held ultrasound devices are being investigated as potential options and could be confirmed as suitable for use in due course.
=== Laundry services ===
All dirty linen should be handled for bagging or binning inside the patient room/cohort area. The clean linen stock should be stored conveniently close to clinical areas, in a dedicated clean area in the uncontaminated zone. Used linen should be stored in a designated, safe, lockable holding area while awaiting collection. Interim storage areas for soiled linen at the wards is allowable; this may be in dirty linen/ utility room.
Any clean linen for PUI areas should be handled in spaces physically separate from dirty linen of confirmed patient areas. It may be necessary to completely separate PUI and confirmed patient linen streams. Soiled linen and clean linen bags and bins should be dedicated and not mixed.
Full laundry cleaning and drying services may be provided on-site or outsourced. If laundry cleaning and drying services were already rendered on or for the host site before it is repurposed as an ACS, then a suitability and risk assessment should be conducted to ensure that the volumes of laundry generated and infection prevention and control measures are conducive and modifications made as necessary. A new full laundry service may take time and resources to establish, and in general, will not be established at a host site as a temporary solution. Where the site and circumstances advocate for the design of a new laundry or the upgrade of an existing laundry, the IUSS Laundry Services for Hospitals should be applied.
==== Siting and model selection considerations ====
When an existing laundry is being assessed for use or a new one is being planned the following considerations apply:
* Water and power capacity.
* Ease of access to the ACS’s main corridors and internal transport routes.
* The noise factor of the facility and its impact on nearby patient care departments.
For outsourced departments:
* Delivery areas to allow sufficient space to ensure that vehicles can manoeuvre and park easily at the reception and dispatch bays.
* Access to the ACS service roads and public roads.
==== Functional requirements ====
The most basic equipment needed in a laundry includes washing machines, tumble dryers and ironing machines. Equipment requiring steam is not recommended for a temporary facility. The sizing of the laundry, equipment and engineering services can be modified based on the principles provided in the IUSS Laundry and linen.
=== Catering services ===
Kitchenettes, that is, areas for tea, coffee and snacks, mainly for staff, in staff pause areas are discussed elsewhere in this document.
Catering services (for staff and patients) may be provided on- or off-site. If the ACS is to be established with easy access to a suitable, existing, functional kitchen service (e.g. hotel, military or hospital catering) which can meet the additional demand of the ACS, then this should be used. If there is no suitable facility, catering should be outsourced via a suitable off-site supplier. Only in the event that no feasible or suitable, existing facility or local supplier is available, should a new catering service be established at the ACS. Detailed guidance for the sizing, design and layout of catering services can be found in the IUSS Catering Services for Hospitals.
The kitchen (for on-site catering) or preparation area (for off-site catering) should be located with easy access to the point of delivery and storage of food. Adequate food and equipment storage space must be provided.
It is recommended that patient and staff meals, where provided, be supplied in disposable, containers, suitable for incineration, and that these are disposed of as risk waste immediately after use.
Where off-site catering is used, a suitable area for receiving should be provided. Space will be required for sorting meals for distribution and collecting and storing dirty dishes, washing dirty dishes, if necessary, and disposing of left-over food and disposable containers and utensils. The size of the areas required for this will depend on the number of meals delivered.

=== CSSD ===
The primary function of a Central Sterile Supply Department (CSSD) is to provide an efficient, economic, continuous and quality supply of disinfected and sterilised items, when needed, to all patient-care service points in the ACS, and to receive returned contaminated items for cleaning.
CSSD with limited sterilisation capacity (autoclave) but sufficient disinfection capacity (instrument washing). The layout requires a designated clean and dirty areas with a hard barrier between to avoid cross-over of staff and equipment. Work is unidirectional - flows from dirty – to clean - to sterile areas.
This yields three distinct zones:
1. Receiving and cleaning with pass-through windows
# Dirty receiving with Perspex or glass partitioning
# Dirty utility
# Decontamination and cleaning/wash area with throughput instrument washing
# Trolley wash/Park – external
2. Inspection, assembly and packaging with pass-through windows
# A tabletop autoclave
# Instrument washer
# Clean Packing area
3. Sterile processing, storage and distribution. (Separate issuing area from receiving area) with pass-through windows
# Store -linen and consumables
# Sterile pack store
# Issue - Collection hatch with Perspex or glass partitioning
Must also have a secure, separate receiving area for consumables receiving and storage.
An example of a CSSD unit is shown in Figure 21.T

[[File:An example of a small CSSD facility.png|600px|thumb|none|An example of a small CSSD facility<ref>IUSS 2014, https://www.iussonline.co.za/norms-standards/support-services/24-central-sterile-service-department</ref>]]

To be understood: Quality of services, eg. water (including a source of distilled or ionised water for rinsing of bronchoscopes) and electricity, quality of management, if equipment is appropriate for needs and fit for purpose, what is required of the equipment in the near and far future (relocation?), compliance with S.A. National Standards for CSSD, compatibility of equipment and devices, correct chemicals, maintenance of equipment, training of operators. Although the use of disposable breathing circuits and accessories (masks) should be encouraged, the capacity to disinfect these items if disposable is not available must be considered.

The CSSD must be sized to serve the ACS. Considerations are workload and space requirements. CFSA has extensive [https://www.fidssa.co.za/Content/Images/CFSA_SOP_2018.pdf standard operating procedures] for CSSD.

Workload: Number and type of procedures, number of procedure rooms, eg for bronchoscopy, operating hours, available inventory, volume of work and peak times, degree of mechanization, eg. manual or automated instrument washing, amount of product to be stored – chemicals, barrier wrap, chemical indicators, etc., storage and distribution records, quality records – eg. equipment checks, disposal needs.

Space requirements: Space for separation of clean and dirty, allow for unidirectional movement, allow space to manoeuvre trolleys (queue, pack/unload), reduce lifting and carrying heavy items, reduce awkward movements, allow for tidy work areas. Insufficient space will compromise sterility!

Preference should be given to construction materials and finishes which are suitable for frequent cleaning and tolerant to chemicals, including bleach (sodium hypochlorite). Impermeable flooring, non-slip and smooth washable walls are needed. Joints at walls and floors and coving at wall edge, and exposed drains should be avoided. Worktops should be sealed and should be ergonomically suitable.

Ceiling heights below 2.8m may be vulnerable to damage from humidity Where steam and moisture are generated. Noise – insulation of washer-disinfector and steriliser in technical walls will reduce noise. Lighting: Natural light if possible – windows sealed. High luminance if artificial lighting. Open, slatted shelves for sterile store area. Sinks for manual washing: At least two basins, deep (25cm at least) basins, 91 cm from floor, wide and long enough for the biggest instrument tray or container, water ports for flushing of lumens.

The CSSD space allocation and layout should be determine based on what procedures and which medical devices will be required. A typical [[equipment list is provided here]].

=== Maintenance and cleaning ===
Maintenance and cleaning services must be accommodated with offices located away from clinical areas.

=== Mortuary services ===
The National Department of Health has issued guidance on handling of dead bodies and infectious remains<ref>National Department of Health South Africa, 2020 [https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf]</ref>, which should be applied to ACS. While some guidelines have recommend that bodies of persons who have died from COVID-19 should only be held for a very brief period prior to cremation or treatment for burial<ref>Zhejiang University, 2020 [http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm]</ref>, the WHO holds the view (at the time of writing) that there is no evidence of persons becoming infected from exposure to bodies during normal ceremonial and burial activities. However, appropriate PPE should be used when handling such bodies with additional airborne precautions to be taken during autopsies<ref>WHO, 24 March 2020 [https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf]</ref>.

Either body cabinets or a refrigerated room could be used for body storage.
==== Location and layout of mortuary service ====
It is likely that not all alternative care sites will have a mortuary. Those without a mortuary must have a holding room that is located away from general access areas. This holding room must be suitably sized and conditioned. A recommended room size is 3.5 m x 3.4 m<ref>IUSS Adult Inpatient Services, 2014, [https://www.iussonline.co.za/docman/document/clinical-services/65-adult-inpatent-services-gazetted/file]</ref>
A mortuary should be located so that it is easily accessible to mortuary staff and related service providers and visitors without presenting either aesthetic, emotional or ethical problems for unrelated staff, patients or visitors. It should be separate from the general facility, allowing access for the family to view a body without passing through any potentially contaminated area of the facility. The visitors’ entrance should be external and completely separate from other access points.
Appropriate routes should be designated so that bodies are not moved through public-access areas.
==== Sizing of mortuary ====
The layout and size of a mortuary are largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.
==== Services ====
The following services are required in a mortuary:
* Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.
* Sluicing facilities are to be provided in both the body-preparation and autopsy areas if they are not a common area.
* Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush-fitted stainless steel grids.
* No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.
* The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.
* Anti-backflow devices should be fitted to the water-supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.
* Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.
==== Finishes ====
Wall and floor finishes should be impervious to liquids and easily cleanable.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Engineering and environmental controls''' ==

=== General indoor environment conditions ===

Existing environmental control systems should be modified to suit requirements in the facility. The following issues should be considered:
* Systems should be set to maximise the introduction of fresh air and maintain the pressure regime (see ventilation).
* The following internal temperature range should be maintained 19 - 24oC.
* Cooling systems should be able to cater for projected internal heat gains from people, lighting and equipment. Indicative heat gains in treatment areas are 8W/m2 from people, 15W/m2 from lighting and 3 W/m2 equipment and in critical care areas 16W/m2 from people, 15W/m2 from lighting and 60W/m2 equipment.
*As heat gain can vary widely between items of equipment, heat gain and utilisation rates for equipment should be obtained from the manufacturer to establish this more accurately.

=== Solid waste from ACS ===
According to the National Department of Health COVID-19 Environmental Health Guidelines
“All solid waste from the facility should be regarded as potentially infectious material and therefore appropriate precautions should be taken". The management of healthcare risk waste (HCRW) should follow the correct identification segregation, storage and disposal processes as indicated in SANS 10248-1.

* HCRW is segregated at the point of generation and shall be containerized to minimize the risk of contamination.
* Waste generated from patients in isolation or quarantine in a designated facility health facility is treated as health care risk waste (HCRW) as per SANS 10248-1-2008.
* The HCRW is properly packaged in a sealed, leak and puncture-proof containers/ boxes.
* The HCRW is labelled with the biohazard symbol/ sign and marked “Corona virus or COVID-19”.
* The HCRW is stored separately from other waste generated.
* The collection, transportation, treatment and disposal is provided by only an appointed/ appropriate contractor/ service provider, however, ensure that waste is safely stored until the health care waste management company can pick it up and that the company knows and acknowledges that waste was generated by suspected or confirmed COVID-19.
* The waste management company collecting must ensure that and treated and disposal is conducted at license waste treatment/ disposal facilities .
* All personnel or staff in contact with patients must be geared with appreciate personal protective equipment (PPE’s) at all times to prevent exposure or risk to health.
* Monitoring should be done at such facilities.
* All, bags, bins and boxes must be adequately sealed, as not to leak any fluids, and must be wiped down with 0.05% chlorine solution

Measures developed should consider the following.
* Develop a waste management plan following national guidelines and best practice standards for the disposal of medical waste (WHO, 2020).
* Establish procedures with medical waste service providers to regularly pick up the waste and dispose of this safely.
* Provision should be made for 5kg of solid waste per bed per day and this should be monitored and supplemented where it appears this may be inadequate.
* Ensure that access to waste is secure and controlled, for instance, by using lockable waste 1000l containers kept in a location that can only be accessed by health facility and nominated service delivery staff.
* Vermin control programs must be implemented throughout the site with HCRW collection points prioritised
* Provision for safe cleaning and disinfection of reusable containers should be provided. Cardboard, single-use HCRW boxes are removed from site and incinerated.
* Waste must not be allowed to accumulate or be stored inappropriate or unsecured containers.

== '''Engineering Services''' ==
Engineering services include patient services, ventilation, electrical power, water, medical gases, oxygen, compressed air, vacuum, lighting, and fire safety that support the needs of the patients and medical staff under normal and emergency situations. Good practice standards are provided in:
* IUSS Building Engineering Services<ref name = "IUSSBES">IUSS 2017, [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file]</ref>
* NHS Nightingale Instruction Manual<ref name="BDP2020">BDP 2020, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf]</ref>.
The guidance below draws on these and other manuals and standards. 

=== Building ventilation ===
==== Mechanical ventilation ====
While SARS-CoV-2 RNA has been detected in aerosol form, in experimental mechanical aerosolization studies, it is primarily spread through droplet and contact spread and the potential for airborne transmission is thought to be low.
However, the following advice is provided by ASHRAE regarding HVAC systems in general spaces (not specific to healthcare):
Effective high levels of ventilation must be achieved in the facility. Existing ventilation systems should be tailored to suit internal layouts and requirements and the following measures should be taken.
* Mechanical systems should be set to maximise fresh air supply to the facility. There should be no recirculated air without HEPA filtration or other validated decontamination processes.
* A pressure regime should be established, as shown in figure 2, to 'push' air from clean areas, to dirty areas and then out of the building.
* A clean air supply of over 10 L/s per person should be targeted for odour control.
* Fresh air supply shall not be located near patient beds to avoid drafts in winter.
* Extraction points can be located near patient beds in isolation wards or at a high level in long-stay wards. Short-circuiting of air between high-level supply and extraction is a performance risk in winter.
* Noise from ventilation systems and fans shall be below 45 dBA
* Protected lobbies, internal partitions, door arrangements, fans and extracts should be used to maintain the pressure regime and airflow as indicated in the diagram below.
 

[[File:Ventilation in temporary facilities.png|600px|thumb|none|Ventilation in temporary facilities<ref name="BDP2020"/>]]

==== Natural ventilation ====
The airflow direction between naturally ventilated zones may fluctuate according to the wind direction. This is not of concern within and between contaminated zones where occupants are either protected with mandatory PPE or confirmed to be infected with disease strains similar enough so as not be able to reinfect others. Where levels of occupant susceptibility to an airborne disease is significantly different, the less susceptible areas (such as PUI areas and uncontaminated areas) shall be protected from the naturally ventilated and contaminated areas by mechanical ventilation systems with a capacity sufficient to overcome the expected natural ventilation pressure fluctuations (typically 5-15Pa). Where such mechanical ventilation systems are not feasible or expected wind pressure is too great, zone adjacently must be avoided.

===Ultraviolet germicidal Irradiation===
The application of Ultraviolet Germicidal Irradiation (UVGI) for room air disinfection is well understood and is proven to be effective in the disinfection of microorganisms including M. tuberculosis (TB) in air. UVGI should, therefore, be considered as a valid element in indoor airborne infection control strategy for high volume settings. Studies have demonstrated the importance of good vertical air mixing in the room, and the safety of UVGI application. In areas where UVGI is indicated, the design and development of UVGI systems should be in accordance with the [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]<ref>van Reenen et al,2019 [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]</ref>

=== Electrical power ===
Sufficient and reliable power must be available at the facility for envisaged medical equipment, medical gases, lighting and building ventilation equipment. Power installations for the temporary facility can be divided into three zones as indicated below. These are existing services, the temporary service zone and services in each bay.
The following should be considered by competent engineering professionals.

=== Existing services ===
*Capacity: Evaluate whether sufficient power to accommodate envisaged medical equipment, additional lighting and heating, building ventilation and air conditioning can be provided. If existing capacity is insufficient, investigate if it is possible to route additional power from additional locations/transformers around the site or from adjacent sites.
* Safety: The existing electrical distribution network must be able to supply the required equipment load. If this is insufficient/appears unreliable, identify how this can be supported.
* Resilience: Evaluate back-up power and a UPS capacity against essential services demand. If existing capacity is not sufficient, source and establish temporary service capacity.

=== Temporary service zones ===
*Identify locations for temporary service zones where equipment can be located.
*Ensure that equipment and maintenance access is safe and easy.
*Ensure that all distribution boards, circuit breakers and cables are clearly labelled.
=== Services in each bay ===
*Provide pre-wired power strips/trunking as per bay requirements.
*Check that these include sufficient electrical outlets and service points for envisaged equipment.
*Ensure that trunking will carry required equipment loadings. The IUSS Building Engineering Services Guide can be used to check requirements<ref name = "IUSSBES"/>.

[[File:Layout_of_power_in_a_temporary_installation.png|600px|thumb|none|Layout of power in a temporary installation <ref name="BDP2020"/>]]
----

=== Water ===
Water points are needed for handwashing, showers and cleaning. The following issues need to be taken into account.
==== Supply ====
Onsite cold water storage, dedicated to the domestic water requirements of the facility, should be provided. A minimum usable volume of 500 litres per bed should be available.
Hot water storage and consumption should be confirmed by an engineer, as follows:
*Storage 25 L per bed.
*Consumption 180 L/bed.day W/O laundry; 250L /bed. day W laundry.

==== Handwashing ====
See infection control for clinical wash-hand basins
==== Showers ====
Showers for staff coming off shift should be available. Staff flow routes exiting contaminated treatment areas should pass through gowning and shower areas.
----

=== Medical gases, oxygen and vacuum (suction) ===
Medical gases, oxygen and vacuum services will be required in the facility. Mobile gas supply requires piping between supply and patient and clutter floor space. Preferably used fixed installations for patient rooms/cubicles, if possible.

System capacity and point of use pressures and consumption rates are to be ensured at all points. WHO provides technical guidance on [https://www.who.int/publications-detail/oxygen-sources-and-distribution-for-covid-19-treatment-centres oxygen sources and distribution]. 
[[File:Medical gas service layout.png|6oopx|thumb|Medical gas service layout<ref name="BDP2020"/>]]
The following points should also be taken into account.
* For centrally supplied medical gas and vacuum services, system resilience and availability must be ensured.
* Compressors, tanks, accumulators, VIEs, headers and controllers must be secured from uncontrolled access.
* Where possible, gas piping should be reticulated below floors or in ceilings to ensure protection from tampering, damage and ease of access.
* Where reticulation is within open areas, high-level reticulation with point-of-use droppers is advised. Low-level reticulation within rooms is to be avoided.
* Flexible piping can be used, ensuring it does not present a contamination or fire risk and should comply with local regulations. Special care should be taken with flexible O2 piping, keeping it to a minimum.
* Vacuum piping may be contaminated, where point-of-use filtration and collection systems fail. Precautions should be taken when demounting or disconnecting temporary vacuum lines.
* Ensure that oxygen pipelines are designed to provide sufficient flow to all oxygen points in the facility. In terms of utilities, oxygen and medical air would be required. A temporary vacuum point can be provided by mobile medical vacuum units distributed throughout the unit.
* Mobile medical air supplies should be considered where reaching piped specifications are not feasible. Where flexible hoses are used for oxygen and medical air special precautions need to be taken. Flexible oxygen piping must be chemically safe for O2 use. Where perishable flexible piping is used for medical air, terminal filtration at the point-of-use may be required at point-of-use. Especially for long-term use.
* Electrical and gas services can be reticulated against pipe racks or boards fixed to the bed-heads for head to head bed arrangements.
* Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.
* Gas service outlets to be labelled and colour-coded with 3mm lettering.
* SANS 7396-1 should be used to specify the requirements from design to commissioning of medical gas and vacuum systems.
* Medical gas and vacuum pipelines shall be marked per SANS 7396-1 and ISO 5359, as applicable.
* Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.
* SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.
* Plain-ended copper tubing for low-pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.
* Laboratory gas taps and valves shall be marked as described in SANS 10140-4.

=== Lighting ===
Existing lighting systems may need to be modified to suit the clinical requirements in the facility. High bay lighting presents inadequate colour rendering quality for the accurate detection or easy diagnosis of certain clinical conditions. This needs to be evaluated in the selection of supplementary lighting systems.
*Lighting levels should be provided in line with the indoor lighting levels recommended in the Table 6 of IUSS Building Engineering Services .
*Mobile task lighting systems may be adopted in the serious and critical stay wards to supplement incorrect lighting quality.
*Emergency lighting and illuminated emergency egress signage should be linked to the back-up power system.
*External security lighting in external parking areas and spaces around the building should be enhanced to ensure the security of medical staff who need to change shifts at night.

=== Fire safety ===
A functional fire alarm system should be available to support the patient care setting. Fire is a very real threat due to the possibility of an oxygen-enriched atmosphere developing so ventilation is crucial.
The use of temporary facilities for medical care should note the following fire risks (NHS, 2020):
*Patients may have a very high dependency.
*Areas are not specifically designed for patients and do not meet guidance on fire compartmentation and progressive horizontal evacuation.
*Large numbers of patients supplied with oxygen up to 10 litres per minute.
*Possibility of oxygen concentrations exceeding those generally found in the atmosphere- less risk if effective ventilation or large volume i.e. high ceilings.
* Possibility of storage, in excess of 40 litres, of alcohol-based chemicals (such as hand-rub), necessitating a flammables cabinet on site.
*Staff who may not normally work together .
*Staff who may not be familiar with the area.
*Staff not trained in fire safety, progressive horizontal evacuation or oxygen isolation for the specific area.
These factors should be taken into account in fire risk assessments which should then address significant findings in an action plan. Fire assessments should be undertaken by a qualified person and shared with operations and building management staff within the facility. Measures developed should include:
*An automatic fire detection system
*An emergency egress plans are prepared that include patients who have a very high dependency.
*Signage, notices and lighting are installed and are working effectively.
*Management processes are in place to minimise the risk of fire from ignition sources, fuels and oxygen.
*Staff are trained and a fire safety guide sheet for staff is developed and issued.
*Emergency egress routes are kept clear.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Additional Resources''' ==
=== [[Directory of Service Providers|A Directory of Service Providers can be viewed here]] ===

=='''References'''==
<references />

[[Category:COVID-19| ]]
[[Category:Alternate Care Sites|Alternate Care Sites]]

----
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19|(Return to Top)]] 
----

Infrastructure Guidance for COVID-19/Alternate Care Sites

2020-05-08T08:49:09Z

Peta: /* Personal protection */

[[Infrastructure Guidance for COVID-19|Return to Infrastructure Guidance for COVID-19]] 

== '''Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19'''==

This guidance work was initiated under the project titled: 
''Reducing Nosocomial and Community-Acquired Tuberculosis by Strengthening the Capacity of the South African Department of Health to Improve Implementation of Infection Control and Waste Management at All Levels of the Health System Under the President's Emergency Plan for AIDS Relief (PEPFAR)'' 

== '''Introduction''' ==
=== Purpose and approach ===
The global pandemic of COVID-19 caused by the coronavirus, SARS-CoV-2 is likely to result in a surge in need for medical care for Severe Acute Respiratory Syndrome (SARS) in South Africa. Considering the course of the pandemic in other countries, it is anticipated that South African hospitals will not have sufficient capacity to cope with the surge of persons requiring medical attention and that surge capacity via alternate care sites (ACS) will need to be established.
Surge capacity, contemplated here is not the frequent emergency department overcrowding experienced by healthcare facilities (e.g. Friday/Saturday night emergencies) or local casualty emergency that might overcrowd nearby facilities and have little to no impact on the overall healthcare delivery system. It is when a catastrophic event occurs and the affected population seek medical care from existing local healthcare facilities, causing healthcare infrastructure to become exhausted due to excess in demand. During a healthcare surge, the standard of care will shift from focusing on patient-based outcomes to population-based outcomes, and providers should anticipate “a shift to providing care and allocating scarce equipment, supplies and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals.”<ref>[https://asprtracie.hhs.gov/technical-resources/resource/491/altered-standards-of-care-in-mass-casualty-events Health Systems Research Inc., 2005]</ref> 

Surge capacity can be temporarily established in non-traditional environments, such as hotels, exhibition halls, community halls, and as field hospitals, on open spaces. 

In the context of this document, a quarantine site is a facility for patients who do not require continuous professional medical care, while an ACS is defined as a temporary facility that can provide continuous medical care for SARS. This document provides principles and considerations, high-level guidance for minimum requirements and examples for ACS. 

While an extensive set of health facility guidelines does exist<ref>[https://www.iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-servi IUSS Building Engineering Services (2017)]</ref>, these are applicable for conventional facilities and thus include services and guidelines that are not necessarily relevant to the treatment of a novel, highly infectious pathogen, with pandemic effects. Moreover, these do not provide well for the rapid and temporary establishment of facilities. 

In order to formulate high-level guidance, [[as invited by Business for South Africa]], the team reached out to professional industry bodies for inputs, in particular the South African Institute for Architects (SAIA), The Gauteng Institute for Architects (GiFA) [https://www.gifa.org.za/ Gauteng Institute for Architecture] and the [http://www.safhe.co.za/ South African Federation of Hospital Engineering (SAFHE)], by inviting input via a 36-hour research charrette. Relevant historical and contemporary literature was consulted, precedents identified and critically reviewed. An interaction with the team at Wuhan responsible for makeshift hospitals and emergency infectious diseases hospitals, Central-South Architectural Design Institute, was arranged with assistance of the Chinese Embassy. Material from the [[Infrastructure Unit System Support|Infrastructure Unit System Support (IUSS)]], international literature and guidance and input gathered from the broader architectural, engineering and healthcare professional communities was synthesised and moderated by the CSIR team. The draft was reviewed by an expert review panel. 
=== Acknowledgement of contribution ===
The contributions to the initial version of this were gratefully received. [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Acknowledgements|A list of these contributors can be viewed here.]]. 
New contributions are eagerly encouraged along with debate and discussion on the [[Talk:Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites|'''discussion forum.''']] tab above.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Scope and Assumptions''' ==
ACSs as discussed in this document are dedicated, temporary facilities for triage, testing, diagnosis, further referral and treatment of persons:
*suspected of having contracted SARS-CoV-2, (persons under investigation (PUIs)), who are symptomatic and/or are awaiting results,
*or are confirmed to be infected.
ACS will accommodate a variety of clinical, logistical, support and auxiliary services associated with the render of care. ACS will currently not be licensed to provide healthcare services. Since the ACS will operate in a non-healthcare facility, it cannot fully replace a hospital setting and its prime objective is to manage the patient load until the local healthcare system can meet demands. 

=== Exclusions ===
Quarantine facilities are accommodation facilities where a member of the community can remain for the duration of their isolation period. This is typically temporary housing for a cohort of people who do not need intensive medical attention but who cannot stay at home. Patients can take care of themselves and need limited monitoring by medical staff. Quarantine: Containing presumptive-case patients from each other and the general population.
Quarantine facilities – that is for asymptomatic persons who are in the community in self- or imposed isolation, but not displaying symptoms, or who are symptomatic, but are able to safely recover without clinical intervention and do not need continuous medical observation are not considered in this document.

=== Service regime ===
The following assumptions are made with respect to services under consideration.
* Temporary - limited to the part of the pandemic when the “conventional” hospital platform cannot meet demand. To be dismantled, thereafter.
* Uncomplicated, dedicated COVID-19 care is to be prioritised for ACS.
* Patients with comorbidities, paediatrics will be prioritised for conventional facilities, and only accommodated in ACS as a matter of last resort.
* 24 hour, 7 days a week operations. 

=== Assumed mechanism of transmission ===
Transmission of SARS-CoV-2 is understood to be from person to person firstly by [https://en.wikipedia.org/wiki/Transmission_(medicine)#Droplet_infection droplet] transmission, then by the [https://en.wikipedia.org/wiki/Transmission_(medicine)#Direct_contact contact] route and finally via airborne [https://en.wikipedia.org/wiki/Transmission_(medicine)#Airborne_airborne transmission] during or following mechanical aerosolisation. Water transmission risks are minor, occurring in special [https://en.wikipedia.org/wiki/Transmission_(medicine)#Fecal%E2%80%93oral Fecal-oral] circumstances. Reclassification of transmission mechanisms may nullify some of the approaches presented in this guidance. 

=== A call for strategic coordination ===
This document focusses on infrastructure requirements. These provisions are meaningless without staffing, equipping and resourcing. Whilst staffing, equipping and resourcing are not the focus of this document, these are likely to emerge as key constraining features. Resource constraints are likely to become acute during this pandemic. Doctors and nurses are already in critical short supply in South Africa and internationally, and are themselves susceptible to COVID-19 infection. Equipment and consumables are in short supply with heightened global demand, reduced manufacturing capacity and limits in trade flows. This necessitates strategic coordination, proactive planning, options appraisal and prioritisation. 

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Status Quo''' ==
=== Rationale and transmission status ===
According to the [https://en.wikipedia.org/wiki/World_Health_Organization World Health Organisation] (WHO), based on the largest cohort of COVID-19 patients, about 40% of patients with COVID-19 may have mild disease, where treatment is mostly symptomatic and does not require inpatient care. About 40% of patients have moderate disease that may require inpatient care; 15% of patients will have severe disease that requires oxygen therapy or other inpatient interventions, and about 5% have critical disease that requires the patient to receive mechanical ventilation. However, the evolution of the outbreak in some countries has shown a higher proportion of severe and critical cases and the need to rapidly increase surge capacity to prevent rapid exhaustion of biomedical supplies and staff. In some countries, doubling rates of cases every three days has been observed<ref>WHO-2019-nCoV-HCF_operations-2020, [https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf]</ref> 

South Africa has a high burden of disease, with a high prevalence of [https://en.wikipedia.org/wiki/HIV/AIDS_in_South_Africa HIV and TB]. Although evidence is yet to emerge of the effect of SARS-CoV-2 on a population with these pre-existing conditions, there is reason to proceed with caution<ref>The Conversation 2020, https://theconversation.com/tb-hiv-and-COVID-19-urgent-questions-as-three-epidemics-collide-134554</ref>. There is a potential direct and indirect benefit of ACS to people living with HIV and TB, as well as to general public health and the health system preservation. 

With the travel lockdown in place, and continued transmission, it appears that South Africa is on the cusp between cluster transmission and community transmission according to WHO’s classification, shown in the [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites#Key_clinical_and_infection_control_activities_for_different_transmission_scenarios_.5B3.5D|table below]], indicating that preparation should include temporary hospital facilities and mass critical care.

==== Key clinical and infection control activities for different transmission scenarios <ref>WHO 2020, [https://apps.who.int/iris/handle/10665/331492 https://apps.who.int/iris/handle/10665/331492]</ref> ====
{| class="wikitable"
|-
! !! '''No Case''' !! '''Sporadic Case''' !! '''Clusters of Cases''' !! '''Community Transmission'''
|-
| Faculty Space, Including for Transmission|| Usual Space. Enhanced Screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards). || More patient care areas re-purposed for COVID-19 within the health system, especially for severe cases || Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Staff|| Usual space. Enhanced screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards)||More patient care areas repurposed for COVID-19 within the health system, especially for severe cases||Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Supplies||
*On-hand supplies. Equip wards for COVID-19 treatment.
*Identify essential equipment and supplies, including oxygen.
*Prepare expanded local supply chain
||
*Expanded inventory of supplies with detailed protocols for use.
*Activate expanded local supply chain.
*Prepare national supply chain.
||
*Conservation, adaptation, selected re-use when safe.
*Activate contingency planning and procurement for essential equipment and supplies.
*National supply chain.
*Prepare expanded supply chain at the global level
||
*Activate contingency planning should critical equipment be in short supply.
*Determine allocation of lifesaving resources for HCWs and patients.
*Activate expanded global supply chain
|-
| Standard of Care|| Usual care with enhanced awareness and recognition of immediate needs for first COVID-19 patients|| Usual care and treatment for all patients, including those with COVID-19||Identify context-relevant core services. Shift service delivery platforms. Consider reduction in elective patient encounters, including elective surgical procedures.|| Mass critical care (e.g. open ICU for cohorted patients).
|-
| Care areas expansion|| No requirements for expansion|| Designate 10 beds per suspected COVID-19 case|| Expand COVID-19 patient care areas by a factor of 35 ||Expand COVID-19 patient care areas by a factor of 58
|}

=== Quantification of need ===
At this time there are various parallel initiatives aimed at forecasting the South African epidemic, quantifying the projected need for facilities, and a shortfall in existing capacity. At this time, there is no consensus on this. This section will be updated as further data becomes available.
ACS will prioritise mild to moderately affected COVID-19 patients where basic, targeted medical care will be provided. Should patients’ needs evolve, requiring escalation of care, then the transfer of patients from ACS sites to conventional sites of care will be needed as a matter of course, bringing with it logistical challenges and risks. In the event that the conventional hospital platform is unable to cope, ACS will have pressure to provide care for severe and critical patients, and finally for patients with comorbidity and special requirements, such as paediatrics, persons living with HIV (PLHIV), TB patients and pregnant women. The following pragmatic approach, aligned with the WHO recommended strategic approach, is suggested.
*ACS should preferably be identified with space for expansion.
*The set-up should be done so that levels of care can be upgraded to higher levels of uncomplicated care.
*A secondary upgrade for more diverse package of care may become necessary.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Strategic Approach''' ==
According to WHO, clinical interventions must be put into place immediately and then scaled up according to the epidemiologic profile.
[[File:COVID-19 Resource allocation.png|none|thumb|600px|right|WHO Strategic approach to clinical care]] 
Under this declared state of disaster, the clinical care strategy which cannot be accommodated within existing facilities, can, on a temporary basis be hosted in ACS:
*Within and around existing healthcare facilities, via reconfiguration and/or augmentation.
*In existing non-healthcare buildings suitable for repurposing, such as universities, hotels and conference centres, warehouses, gyms, hostels etc.
*On open fields, including paved parking areas with rapidly constructed, dismountable structures, such as modular tented structures or using rapid modular construction techniques. 

ACS will provide isolation, general (non-acute) care for patients with mild to moderate symptoms and as required, acute care for patients with severe symptoms. Containing confirmed-case patients from general population. Confirmed-case patients can be housed together en masse, while presumptive-case patients must be individually quarantined.
As shown in the WHO Strategic approach to clinical care, the WHO recommends a range of services to meet patient need (''Citation needed''). General (non-acute) care ACS model is designed for minimal acuity patients requiring minimal activities of daily living support (e.g. COVID-positive with minimal symptoms or require <2L of oxygen). Acute care ACS model is designed for higher acuity patients requiring closer monitoring or respiratory support (e.g. COVID-positive with pneumonia or respiratory distress requiring ventilator support). Paediatric patients are to be accommodated in separate wards, where strictly controlled visitation may be allowed. 
As a preliminary estimate, the following ratios of service is proposed:
[[File:COVID Ratios of Service.png|none|thumb|600px|center|COVID Ratios of Service]]

{| class="wikitable"
|-
! '''Case severity, risk factors<ref group="Notes"> Test suspect COVID-19 cases according to diagnostic strategy</ref><ref group="Note"> Known risk factors for severe COVID-19: age over 60 years, hypertension, diabetes, cardiovascular disease, chronic respiratory disease, immunocompromising conditions.</ref>''' !! '''Recommendations'''
|-
|Mild || Patient should be instructed to self-isolate and contact COVID-19 information line for advice on testing
and referral.
|-
|Moderate, with no risk factors ||Test suspected COVID-19 cases according to diagnostic strategy. Isolation/ cohorting in:
* Health facilities, if resources allow;
* Community facilities (e.g. stadiums, gymnasiums, hotels) with access to rapid health advice
(i.e. adjacent COVID-19 designated health post/EMT-type 1, telemedicine)
*Self-isolation at home according to National guidance
|-
| Moderate, with risk factors || Patient should be instructed to self-isolate and call COVID-19 hotline for emergency referral as soon as possible
|-
|Severe || Hospitalization for isolation (or cohorting) and inpatient treatment.
|-
|Critical|| Hospitalization for isolation (or cohorting) and inpatient treatment.
|}

=== Notes and References: ===

<references group = "Note" />
<references />

=== Typology dictates & case studies ===

[[File:NHS Nightingale Hospital London.png|thumb|NHS Nightingale Hospital London <ref name="NHS Nightingale Hospital London">Coronavirus: Building NHS Nightingale Hospital London, 2020 [https://www.bbc.com/news/in-pictures-52092253 https://www.bbc.com/news]</ref>, ]]
To meet the requirements set out in this guidance, prospective “host” sites should be carefully evaluated. The type of “host” site selected will strongly influence or dictate the choice of ACS service model.

No site is likely to meet all requirements and recommendations set out in this document. Adaptations and compromises will be necessary. Services should be provided on site where it is pragmatic to do so, for example where similar services are provided. Outsourcing can also be practical/feasible for some services, such as laboratory services, catering and laundry, provided suitable logistical arrangements can be made.

Some typological responses and service models are set out in precedent examples, shown below. The examples demonstrate that a variety of host settings are workable, provided that the appropriate utility can be contrived.

=== Pragmatic approach ===
Other than in metropolitan areas, co-location of ACS on the premises of, or adjacent to existing healthcare facilities will often be preferable because this is where intensivists and specialist clinical staffing will be available, and support services may be well established. Nevertheless, augmenting capacity at existing facilities should take into account current workloads and capacity to ensure that the COVID-19 surge disrupts normal service provision as little as possible, including continuity of care for patients with chronic conditions and TB and HIV patients. 

*'''[[Infrastructure Guidance for COVID-19/Alternate Care Sites/Case Studies|SARS ACS Precedents and Case Studies can be found here]] '''

=== Notes and References ===
<references />

== '''ACS Infrastructure Planning''' ==

=== Establishing a team ===
A planning team should be formalised to establish the minimum planning and operational requirements for the ACS and to liaise with the local community. The team should include individuals with expertise in the following areas (ideally with knowledge of healthcare delivery under emergency conditions):
*Disaster response / emergency management coordination,
*Clinical care and staffing,
*Infection Prevention and Control practitioners must be involved in all stages of planning, commissioning, in-use, and decommissioning of the facility
*Facility set-up, operations and management,
*Security,
*Transport (patient, staff),
*Engineering and project management,
*Procurement and coordination of supplies, equipment and pharmaceuticals, and
*Community liaison to ensure that concerns of the adjacent population on understood an addressed.
It is important to ensure compliance with health, safety and building regulations, by ensuring the involvement of relevant local authorities. Stakeholder engagement should be formally documented. Concerns and grievances should be systematically addressed.

=== Structural integrity and operational responsibility ===

'''Structural modifications:''' ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered. 

'''Competent person:''' All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed. 

'''Asset responsibility:''' Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented. 

'''Integrity and responsibility'''

'''Structural modifications''': ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered.

'''Competent person''': All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed.

'''Asset responsibility''': Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented.

'''Decommissioning''': Decommissioning of the facility shall be assigned to the competent person discussed above. All residual structures upon decommissioning shall comply with the National Building Regulations. Upon decommissioning, removal of equipment shall be the responsibility of the owner. An infection prevention and control practitioner should be engaged in the decommissioning phase to oversee terminal cleaning and disinfection of equipment and premises.

'''Closure''': Once all patients can be safely discharged or transported back to existing facilities for continued care and there are no ongoing healthcare surge capacity needs, the ACS can be closed. Shut down of an ACS will require decommissioning, identification of new homes or storage for equipment, and termination of ongoing contracts or arrangements. Shut down should be expedited so that the facility can quickly be returned to the control of the existing owners and returned to its usual function.

Action checklist items for ACS closure should include, but not be limited to, the following:
*conduct a site walk-through with the facility owner when shutdown activities are completed to ensure that terminal cleaning and disinfection of supplies and premises, removal of equipment and supplies, and other surge closure activities have been completed to the owner’s satisfaction.
*perform medical records storage procedures.

== '''Site Selection''' ==
When selecting a site, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital can be utilised to determine whether the site is suitable for a 100, 1000 or 2000 bed facility, as required. The following indicative minimum site sizes are needed:
*100 Bed ACS/ hospital conversion, requires ± 4 300 m2
*1000 Bed ACS/ hospital conversion, requires ± 17 600 m2
Evaluation should be done by examining plans (if available), satellite images, drone images, scans and by physical inspection (walkabout). A comprehensive photographic survey should be undertaken and retained for record purposes on the site inspection. This will serve as an audit record and may assist in returning the site to its original function on ACS decommissioning and closure. When scrutinising documents and conducting site inspections to confirm the suitability of a site to host an ACS, the following criteria should be taken into account.
=== Criteria ===
*Affordability (costs, including operational costs known and budget identified),
*Sufficient physical space and capacity to house the immediate need, with the potential to accommodate physical space requirements. For example, open site should not be sloping,
*Legal rights and encumbrances, including renewal opportunity,
*Good access to highway and main roads,
*Well secured perimeter and limited controlled access points,
*Proximity to other hospitals and care sites,
*Accessibility for key staff and public transport,
*Good vehicular access around the site to set up temporary equipment such as back-up generators,
*Free from clear and present danger,
*Outside attenuation zones, floodplains,
*Outside high wind zones,
*Structure in good repair,
*Effective onsite facilities management team who understand how systems work,
*Potential for expansion, if required,
*Access to sufficient capacity for
**potable water,
**adequate sewage,
**telephone,
**internet access with sufficient bandwidth,
**electricity,
*A zone for cleaning, disinfection, and decontamination of equipment at least 15 metres away from occupied areas with access to water, a hard impervious surface and drying areas in the sun, with runoff discharge into the sewer and not into marine ecosystems or the environment. Include area for cleaning and storage of cleaning equipment.
*Likelihood of acceptance of hosting an ACS by the adjacent and local community

=== Desirable ===
*Durable, cleanable surfaces,
*Large open spaces that can be converted to accommodate temporary structures,
*Good ventilation,
*On-site kitchen and laundry,
*Housekeeping staff (chemical and equipment storage, lockers, rest facility, administration office),
*Space conducive for staff respite area and locker rooms,
*Amenities with universal access,
*Fire protection safety and equipment,
*Elevator access for patients if the building has more than one floor,
*Capacity for expansion, and
*Accessible to at least two roadways to provide continued access in the event that one roadway becomes blocked on inaccessible.

== '''Infection Prevention and Control''' ==
General guidance for COVID-19 [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|Infection Prevention and Control]] can be accessed [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|here]] 

Infection prevention and control in the context of COVID-19 should respond to transmission routes of primary concern for the pathogen of interest (droplet and contact transmission, and management of risk waste) as well as infection risk of a general nature (water and sewerage, airborne transmission – under high TB/HIV burden, and general waste).
In addition to satisfying [https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html standard precautions for all patient care], transmission-based precautions should focus on three pillars: exposure reduction by spatial configuration, operational strategies, and personal protection.
=== Transmission-based precautions ===
'''Droplet and contact spread''': Transmission of SARS-CoV-2 virus occurs via droplet and contact spread. The virus has been shown to persist on surfaces for extended periods of time and is known to be efficient at infecting people. 

'''Medical waste and linen:''' As SARS-CoV-02 is carried in body fluids and faecal matter, disposal of contaminated items (tissues) and cleaning regimes (spaces, garments, linen) should be accommodated carefully in the workflow design and infrastructure provision. A site-specific waste management plan should be formulated in accordance with a site-specific waste management plan with reference to SANS 10248. 

'''Airborne transmission:''' Under exceptional circumstances, the risk of airborne transmission arises for SARS-CoV-2, as detailed below.
{| class="wikitable"
|-
!Airborne Transmission Risk Factors
|-
|
As SARS-CoV-2 is not considered airborne, respiratory protection against airborne transmission is not considered necessary, except where aerosolisation of particles may be a risk.
According to the CDC
*tracheal intubation,
*non-invasive ventilation,
*tracheotomy,
*cardiopulmonary resuscitation, or
*manual ventilation before intubation and bronchoscopy.
According to doctors in the field also when performing
*COVID-19 diagnostic sampling as patients can be induced to cough and sneeze.
*Suspected or confirmed comorbidity of TB is not an additional risk where correct COVID-19 PPE is applied.

|}
South Africa has a high prevalence of TB and HIV, and therefore, although the risk of COVID-19 transmission via the airborne route is not paramount, there is a high likelihood that undiagnosed TB infectious patients may present at the ACS for treatment. TB triage may be challenging in the ACS as there are symptoms in common (coughing) with COVID-19. This country-specific risk is taken into account in this guidance

=== Additional precautions ===
'''Water and sewerage contamination:''' The International Water Association [[Infrastructure Guidance for COVID-19/Alternate Care Sites/COVID-19 A Water Professionals Perspective|concluded]] that water and sewerage contamination is not considered to be a key risk factor for COVID-19. The panel expressed concern for “how waste and specifically wastewater (medical) would be handled by places (e.g., hostels, hotels) that are used to serve as interim COVID-19 quarantine or testing facilities or accommodation ([ACS]. These are places other than hospitals that are used in the interim for such purposes and do not usually handle wastewater from medical settings. Such facilities should be monitored carefully.” 

== '''Spatial Strategies for Infection Prevention and Control''' ==

=== Restricted access and zone control ===
The site will be arranged to establish clear zoning, with a clear restricted zone protocol and access protection. Zones should be deemed to be "contaminated" or "uncontaminated" with clear transition areas between them.

; Contaminated zones
: (also known as "dirty areas") are areas occupied by COVID-19 infected persons, PUIs, equipment, materials and supplies which have come into contact with such persons without yet undergoing a decontamination procedure. These areas will include patient ward areas and ablutions, patient admissions (including ambulance drop-off) and the associated clinical areas. Staff rest and dining facilities should be outside the contaminated zone. Limited stock for immediate use should be kept in the contaminated zone. Layout designs should consolidate contaminated zones as far as reasonable, and avoid uncontaminated zones as islands in contaminated zones.

; Uncontaminated zones
: (also known as "clean areas") are areas not generally occupied by PUIs or confirmed COVID-19 infected persons. Equipment, materials and supplies in these areas have not yet come into contact with contaminated zones or have undergone a decontamination procedure. These will include clinical management planning rooms, stock rooms, bulk stores, pharmacy, laboratory areas, kitchen and laundry.

; Transition zones
: (also known as intermediate zone) are the spaces through which transfer of people and goods from uncontaminated to decontaminated zones, and vice versa, occur. Materials from the contaminated zone should be decontaminated or contained in the transition zone. The transfer of goods and persons should be highly ritualised and, as far as possible, traffic across transition zones should be minimised. Transition areas should be strategically located to serve this function. Separation of in-going and out-going transfer of goods and persons is preferable. Transition areas include ambulance, trolley decontamination, CSSD, laundry and waste bagging areas, patient locker area and staff change areas with spaces for donning and doffing of PPE.

=== Site layout and master-planning ===
Spatial configuration and layout can ensure unnecessary cross-over of function is avoided. This entails the systematic separation of functions and the managed transition between activities to facilitate consistency of care, an orderly, efficient work environment, less waste and reduced risk for improved outcomes. To achieve this, functional relationships should first be considered at the site level before being considered at the building level. 

<gallery mode=packed heights=300px style="text-align:left">
Layout for a SARS facility, clustering functions with minimised cross-over.png|center|thumb|Layout for a SARS facility, clustering functions with minimised cross-over <ref name="Layout1">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Layout_for_a_Patient_cohorting_strategy.png|center|thumb|Layout for a Patient cohorting strategy <ref name="Layout3">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Tygerberg Hospital virus triage unit site layout.png|center|thumb|Tygerberg Hospital virus triage unit site layout <ref name="Western Cape Provincial Government, 2020a">Western Cape Provincial Government, 2020 a</ref>
</gallery>

The WHO's Clustering Layout <ref name="Layout1"/> and Tygerberg Hospital virus triage unit<ref name="Western Cape Provincial Government, 2020a"/> show worked examples of building and site layouts, which are configured with these principles, respectively. '''Cohorting''' is defined as clustering patients with similar or compatible clinical needs together for risk reduction, acuity, efficiency and quality management, as illustrated in WHO's Cohorting Layout <ref name="Layout3"/>

=== Workflow ===
Within individual functional zones, the workflow activities can be arranged to proceed from clean procedures to contaminated procedures. In the example below, the staff arrival, PPE donning, doffing and patient flows are worked to have controlled interaction and minimised cross-over

<gallery mode=packed heights=400px >
ACS HCW Flow.png |ACS Health Care Worker Flow
COVID-19 Workflow in small unit.png |COVID-19 Workflow in Small Testing Unit <ref name="Western Cape Provincial Government, 2020b>Western Cape Provincial Government, 2020 b</ref>
COVID-19 Workflow in large unit.png |COVID-19 Workflow in Large Testing Unit <ref name="Western Cape Provincial Government, 2020b"/>
</gallery>

As far as possible, a single direction flow of clean to dirty is recommended for all processes: support services, supply and waste.
The Small ACS unit workflow diagram<ref name="Western Cape Provincial Government, 2020b"/> illustrates the recommended separation of access and exit, separate waiting seats, for persons who may be COVID-19 infected. Separate spaces are provided for donning and doffing PPE. Staff change areas are provided.

In the Large ACS unit workflow diagram <ref name="Western Cape Provincial Government, 2020b"/>, there is a clear separation between staff areas and patient areas. Waiting seats are set far apart to reduce transmission risk. Staff change rooms are provided near the point of entry to the facility for staff to change from street clothes into medical work clothes. To prevent work clothes worn inside the facility from contaminating street clothes, these are kept in separate lockers. A step-over barrier from dirty to clean sides of the change room is helpful to enforce a mind-set of avoiding cross-contamination. Bins for contaminated garments are to be provided in change rooms. Shower facilities are to be provided for staff.

== '''Operational Strategies''' ==
=== Cleaning, disinfection and decontamination ===
Surface and substrate specification, and detailing of all areas should, as far as possible, allow for frequent:
*Cleaning with detergent and water.
*Disinfection with 75% alcohol solution (metal surfaces).
*[https://en.wikipedia.org/wiki/Sodium_hypochlorite Sodium hypochlorite] (1,000 ppm)/ Household bleach.
*Disinfectants listed on the EPA List N<ref>The United States Environmental Protection Agency, [https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 List N: Disinfectants for Use Against SARS-CoV-2 (Last Visited 2020) ]</ref> (for non-critical environmental cleaning).
*High-intensity ultraviolet surface disinfection (UV-C).
*Decontamination and sterilisation of clinical equipment.

=== Goods and waste management ===
Remove any unnecessary furniture, equipment and paraphernalia from all patient care and clinical areas. Provide a clear, secure space for waste management. Any potentially infectious waste materials generated at the ACS should be considered and treated as medical waste (health care risk waste). The applicable legislation is:
*[https://www.gov.za/sites/default/files/gcis_document/201409/35405gen452.pdf The National and Provincial Health Care Risk Waste Management Regulations].
*[https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf National Department of Health COVID-19 Environmental Health Guidelines.]<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>
Waste disposal bins should be positioned near the exit inside each patient rooms or wards to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another patient in the same room.

=== Materials and finishes ===
Floor materials must be:
*Level,
*Free of dust and oil,
*Impervious and smooth,
*Slip-resistant in wet areas (e.g. patient ablutions).
Smooth, cement screed floors are acceptable. Where hosting facilities have carpeted areas, a risk assessment of factors such as durability, hygiene and decontamination needs to be conducted. In cases where the acceptance of carpeted flooring is contradicted (but other factors make it a compelling option), temporary floor finishes or covering can be investigated.

== '''Personal Protection''' ==
=== Hand sanitation ===
Where wash-hand basins are not provided, clinical wash-hand basins should be installed, at the minimum rate of provision of one wash-hand basin per 5 beds. Clinical wash-hand basins (see figure below) have a variety of features not present in standard wash-hand basins, which are preferable for infection prevention and control. Where standard wash-hand basins are provided, an upgrade is not necessary. In all cases, there should be no surfaces and no clutter, equipment or supplies in the vicinity of wash-hand basins, including surgical gloves.
<gallery mode=packed heights=400px>
Clinical hand wash basin.png|Handwash Basin <ref>de Jager 2020</ref>
Portable Wash-hand Basin.png|Portable wash hand basins can be provided in ACS <ref name="BDPa">BDP 2020, NHS nightingale instruction manual, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf</ref>
</gallery>

Where wash-hand basins are not available, portable units can be used, as shown above<ref name="BDPa"/>. Mounted brackets for hand sanitisers are to be provided for every two beds, preferably mounted near the foot rather than the head of the bed and at all common touch points such as entry points at ablution facilities, linen room, sluice, storerooms, medicine rooms/cupboards, near refrigerators, telephones, light switches, at entry/exit doors, etc.

=== Personal protective equipment ===
Donning and doffing points for personal protective equipment, and convenient, safe disposal of consumables to be placed at critical key points when entering patient areas.
----

== '''General transmission mitigation''' ==
=== Water and sanitation ===
To comply with National Building Regulations; Hazardous Biological Agents Regulations and National Department of Health COVID-19 Environmental Health Guidelines<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>.

=== Droplet aerosolisation ===
When designating areas for procedures during which aerosolization and airborne transmission risk is high, the building ventilation must be carefully considered to take into account downstream risks. In particular, consider to where potentially contaminated air, arising from aerosol-generating procedures, is exhausted. In general, air exhausted directly to the outside is diluted and considered safe, unless there are openings to occupied spaces near the exhaust air outlet. 

In the event that potentially occupied spaces will receive partially diluted or undiluted contaminated air, or where this is indeterminate, the aerosolising activity should be designated to an alternate area. In the event that an alternative is not available, some treatment regime (air filtration or air disinfection) is necessary. 

In most naturally ventilated settings, the airflow direction between zones may fluctuate according to the wind direction. Such high-risk spaces should not be adjacent to spaces with high susceptibility rates, such as PUI areas and uncontaminated areas. Contaminated areas should not be directly adjacent to clean areas unless mechanically ventilated. 
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|Guidance on COVID-19 building ventilation design is provided here]].

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Health, Safety and Well-being''' ==
In addition to the infection prevention and control measures discussed above, the following should be provided for health, safety and well-being.
=== General provisions ===
*Minimised and controlled entry and exit points, with suitable control.
*Clearly identified accessible and marked routes for patients, staff, goods and waste.
*Clear designation of restricted zones.
=== Site level provisions ===
*Safe staff parking and arrival of staff via planned and public transport.
*Clearly demarcated parking for people with disabilities.
*Arrival and departure point for patients via public transport, passenger vehicles, and emergency service.
*Limited safe patient parking.
*Supply of goods and removal of waste.

=== Within and between buildings ===
*Entrances with a clear opening width (CoW) of at least 900mm.
*Routes with a minimum width of 2 000mm free of hazards, for example, rubbish bins.
*All clinical, patient and support areas to be accessible by trolley.
'''Ramps''' should be of stable construction, capable of sustaining a mass of 300kg. They should incorporate side lips and the surface should be slip-resistant. Gradients should be as gentle as the circumstances allow. (Recommended maximum 1:20). 
'''Small changes in floor levels''' are not desirable, but where these exist are to be clearly marked with reflective paint/ tape, and lit at night
Elevators between different floors, where patients need access (The recommended minimum lift size for patient trolley/stretcher movement is 1 400mm × 2 400mm, however, this may not be possible). 
'''Pathways''' to be lit at night, where used at night. 
'''Staircases''' must be well-lit at night with non-slip surfaces and secure balustrades. 
'''Doors''', Double doors and automated or push-operated doors to all clinical areas are to be preferred, where these are newly installed or able to be retrofitted. Door closers are to be disabled, where not necessary to reduce touch surfaces. Hand sanitisers to be provided at where high touch common surfaces occur (e.g. wall-mounted at doorways).

=== Signage ===
The appropriate level of information to facilitate legibility, orientation and wayfinding. Minimum standards, signage to be:
*Clearly visible, simple font, font size, contrasting colours, placed in the field of vision
*Washable
*Comprehensive safety signage - fire signage (exits, equipment etc.)
*Restricted areas clearly marked
*Identification signage - each patient space to be allocated a unique number and a whiteboard or perspex sheet for writing the patient’s name
Signs should be posted immediately outside of patient rooms indicating appropriate IPC precautions and required personal protective equipment (PPE).
Signage of a temporary nature can be provided on laminated white A4 sheets attached eye-level. The text should be black sans-serif (for instance Arial) text at least 40point size and centrally positioned on the sheet. Detailed guidance on signage is provided in IUSS Inclusive environments.
=== Safety and security ===
Upon identification of the ACS host site, a team should be convened to conduct a multidisciplinary safety and security analysis. These critical team members need to form the working committee responsible for undertaking the detailed assessment of the existing facility’s security. They should analyse data about the security system’s condition and review existing security concerns or issues that are reasonably likely to become concerns in the near future. The figure below represents a five-zone approach to security, which is a recommended, systematic approach to security.
[[File:Zonal approach to security.png|center|600px|thumb|IUSS Security- Zonal Approach to Security <ref name="IUSS Security">IUSS Hospital design principles - Security [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file]</ref>]]
The security strategy should take into account that whilst clinical services and some logistical and support services will be required 24 hours a day, seven days per week, some support services, logistics services and auxiliary services may only be operational for the minimum periods required to meet demand. These functional elements should be capable of being secured, for example over weekends and at night, as the case may be.
Detailed guidance is available in [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file IUSS Hospital design principles - Security] <ref name="IUSS Security"/>

=== Comfort and dignity ===
Supplemental heating: Patient health and comfort are dependent on, amongst others, maintaining body temperature. The ACS structural technology must be selected to achieve the general indoor environment conditions discussed in a subsequent section for all clinical and occupied areas. As we are moving into South African winter supplemental heating may be required, especially in the evenings, in order to avoid hypothermia. Use of fans, bar, radiator or gas heaters should be prohibited. Unless clinical areas can be maintained above 18 degrees centigrade, patients should each have an infrared heater available, in addition to blankets. Personal/ donated blankets can be considered if they are laundered first and could be destroyed upon discharge.
Mobile screens should be available to provide privacy where necessary (e.g. during consultations or procedures).
<gallery mode = packed heights = 400px>
Bed_Isolator_-Vietnam.png|thumb|Flexible Barrier Isolator<ref>WHO. (2020), Severe Acute Respiratory Infections Treatment Centre. Geneva, Switzerland : WHO- World Health Organization</ref>
ACS Cohort beds.png|ACS Cohort beds.png|thumb|Excel Centre London 04-2020 <ref>Architects' Journal 2020, [https://www.architectsjournal.co.uk/news/nhs-nightingale-bdp-on-the-first-nine-days-converting-the-excel-centre/10046749.article https://www.architectsjournal.co.uk/news]</ref>
</gallery>
Some solutions which address patient privacy and dignity are depicted above.

=== Notes ===
<references/>

== '''Schedule of Accommodation''' ==
Based on clinical needs of the ACS, a schedule of accommodation can be crafted capturing the clinical, clinical, logistical, support and auxiliary services associated with the render of care. When deriving a schedule of accommodation, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital tool can be used. Functions to be accommodated are: 
'''Clinical services''': Triage, rapid assessment of persons entering the facility, to expeditiously identify and render the appropriate service. Admissions and registration. Inpatient accommodation is to be organised according to cohorting principles, discussed above. Testing and diagnostics, including laboratories and x-ray. Safe storage and dispensing of drugs to patients.Offices for clinical administration and clinical planning meeting rooms in the clean zone are needed. 
'''Logistical services:''' Logistical services will entail management of flows of people, goods, services and information to and from the site, as well as within the site. It includes security and communication arrangements. Staff entry, preparations to transition from outside to clinical work environment, including pause areas for relief. Emergency services, visitors. Goods, supplies and storage and waste removal and/ or treatment.
Support services key to the provision of clinical services should be separated so that the risks associated with that particular activity can be managed. 
'''Support services are:'''
*Laboratory services
*Catering
*Laundry
*Environmental cleaning and housekeeping
*CSSD
*Maintenance and cleaning of surrounds, eg. waste areas
*Porters/”runners”, stretchers/wheelchairs
*Mortuary
* Security
Support services can be provided off-site, in which case, safe, secure and efficient transfer and logistical arrangements should be designed. 
'''Auxiliary services:''' Auxiliary services are services which may be provided on or near the ACS site, but which are not directly related to core clinical care. This included overnight accommodation for staff who may not wish to return home to avoid exposing their families, or who need rest between shifts, or for discharged patients awaiting transport home, volunteers who have recovered from SARS-CoV-2.
Limited psychosocial services and allied health services may also be provided on or near ACS for example by approved partners.
Examples of schedules of accommodation for patient and support spaces for a protective isolation ward is available [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedule for COVID-19 Isolation Wards|here]] and mild to severe cases [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedules for COVID-19 Wards for Mild to Severe Cases|here]].

== '''Clinical Services''' ==
=== Triage ===
Confirmed COVID-19 cases and PUIs who are referred from a testing facility or a higher level of care, will enter the facility in a triage area to receive vital screening and initial assessment. They will be registered and admitted to inpatient care. They will be assigned a "ward" or section of the facility - based on disease status and acuity. These are Protective Isolation, the Mild & Moderate ward, or the Critical & Severe wards. Patients should be clustered according to gender. As far as practicable, ablutions for each gender, isolation patients, paediatrics and staff shall be separately provided. Paediatrics patients, if admitted, are to be assigned a dedicated section.
As patients recover or deteriorate, they may be relocated to the appropriate section/ ward.
Once the patient has sufficiently recovered and a negative test result is received they will be appropriately decontaminated and discharged, collecting medication from the dispensary on exit. Patient movement between various sections of the ACS will be restricted as far as possible, with mobile radiology units, in-ward medication dispensing and in-ward food service.

=== Inpatient ACS accommodation ===
Separate spaces for:
*suspected, unconfirmed cases, under observation (PUIs), to be accommodated in isolation facilities (separate rooms, if possible);
*patients with confirmed COVID-19 with mild to moderate disease, not requiring dedicated oxygen therapy;
*patients who require dedicated oxygen therapy;
*patients requiring mechanical ventilation; and
*recovered/ confirmed negative.
==== Protective Isolation Facilities ====
Suspected, unconfirmed cases, under observation – persons under investigation (PUIs) to be accommodated in protective isolation facilities (separate positive-pressure rooms, if possible). PUI are restricted to their rooms. All food and laundry services will be brought to the PUI rooms to reduce interaction and potential contamination. All waste will be collected by facility staff and taken to waste handling areas. Infection prevention and control measures are put in place for the handling of used food utensil and laundry as well as waste collection. PUI areas will have restricted access, including for staff serving other inpatient sections, for confirmed cases.

==== Inpatients accommodation for confirmed COVID-19 ====

Inpatient facilities confirmed positive COVID-19 can be accommodated in large shared ‘wards’ with partitioning between patients. Partitioning between patients is optional. Partitioning is preferable to curtains found in conventional hospitals, as they are more conducive to daily cleaning. If curtains are used, antimicrobial treated fabrics with biocide used to treat the curtains has been tested to international standard EN 14476 and shown to be effective against H1N1 Influenza A Virus (Swine Flu), >99.999% kill rate in 5 minutes and measles morbillivirus, >99.99% kill rate in 5 minutes are preferred. If only separate rooms are available, patient monitoring and surveillance will need to be accommodated. This phase of treatment has a lower area/space requirement compared with PUIs, as cross-infection between patients is less of a concern. Shared ablution facilities are acceptable. It is recommended that, at least, two general accommodation ward areas be provided. 

a) Mild and moderate patients, and 
b) Serious and critical patients. 

The room must have openable windows for natural ventilation if a dedicated positive pressure ventilation system is not available. Ducted ventilation systems shall not be shared between PUI areas and confirmed COVID-19 patient areas. 
[[File:COVID-19 ACS - protective isolation – bed layout.png|thumb|center|800px|ACS - protective isolation – bed layout]]
[[File:COVID-19 ACS – mild-moderate patient bed layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient bed layout]]
[[File:COVID-19 ACS – mild-moderate patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient shared ward layout]]
[[File:COVID-19 ACS – severe-critical patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – severe-critical patient shared ward layout]]

Examples above show bed layout with bed spacing for protective isolation, a mild/moderate patient and a mild/moderate patient shared ward and for a severe/critical patient

=== Patient services ===
Patients in ACS will not generally be ambulatory and will be confined to their room, or cubicle in a bed. In general, domestic beds or hospitality industry (hotel) beds are not suitable for patient care. These should only be used where a hospital-grade bed cannot be sourced, as hospital beds are designed for ease of cleaning and decontamination (for infection prevention and control) and with patient and ergonomics, safety and comfort taken into account (they prevent back injury for nursing staff and can help to prevent bedsores). The higher the specification of bed, the more suitable it is for the higher levels of care. Lockers for patients personal belongings should be provided in the uncontaminated zone (in which case bedside lockers will not be necessary), and it is preferable (where bedside lockers are not provided) for overbed tables to be provided, per bed, if possible. 
The following beds are suitable:
*Repaired and refurbished beds from condemned hospital stocks.
*South African National Standard, SANS 521:2013 Edition 3.5, on Hospital beds and cots ISBN 978-0-626-28830-3.
*Beds listed on the National Treasury (See [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Hospital Bed Specification|specification]]).
The table below details the minimum services required at each patient bed. Details on these services are discussed in a subsequent section of the document.

{| class="wikitable"
|-
! Service/ Capacity!!Triage!!Isolation !!Mild – moderate inpatient!!Severe case wards!!Critical case wards
|-
| Power – 16A 230V Single socket outlet||As needed ||1 per bed||1 per bed||3 per bed||6 per bed
|-
| UPS Power – 16A 230V Single socket outlet ||As needed||1 per bed||1 per bed||1 per bed||2 per bed
|-
| Medical Air<ref group="Note">Mobile units recommended for intermittent use. 3 per 20 beds</ref><ref group="Note">There are some ventilators which have built-in compressors allowing them to function without Medical Air. This is however, not the norm. With Ventilators probably being the most difficult medical device to obtain at present, it would be prudent to rather allow for Medical Air at each bed.</ref> (LP)400kPa||No||Yes||No||Yes||Yes
|-
| Medical O2 -400kPa||Portable/shared||Portable/shared||No||One||Two
|-
| Vacuum-40kPa||No||Portable/shared||Portable/shared||Yes||Yes
|-
| Equipment rail||||||||Yes||Yes
|-
| Upper room UVGI||Optional||Optional||||||Optional
|-
| Examination light||No||No||Yes||Yes||Yes
|-
| Room Ventilation rate||60 L/s per person||10 L/s per person||10 L/s per person||10 L/s per person||12 ACH
|}
'''Notes: '''
<references group="Note" />

Two additional 16A 230V single socket outlets, one two-pin outlet and a worktop should be provided for every 32 beds (or part thereof), for:
*Electrocardiograph (ECG): Could be omitted if monitors have a full 12 lead ECG function.
*Blood gas analyser: Could be omitted if a Lab Services are available.
*Staff cellphone charging.

Example of healthcare technology to be provided for critical care patients is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]. Severe patients may be provided continuous positive airway pressure (CPAP). Emergency trolleys (“crash carts”) are to be provided in patient areas with convenient access to patient beds, out of the passage of corridors and is moved to the patient when needed. 1 crash cart for every 16 patients (or part thereof, with at least one dedicated for PUIs. An example of provisions for a crash cart is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]
==== Patient ablutions ====
[[SARS-CoV-2 is found in faecal matter]], so careful management of patient body fluids is crucial and convenient, practical support for frequent cleaning of ablutions especially shared ablutions is necessary. Dedicated ablutions (toilets and showers) are to be provided for patient use. Toilets and showers should be in separate rooms.
Hand washbasins and or/ hand sanitiser should be provided both inside and outside the toilet room so that patients can wash their hands on the way in and on the way out of the room.
*1 toilet for every 8 persons.
*1 shower for every 8 persons.
*1 disabled ablution for every 8 regular ablutions (or part thereof).
*1 disabled shower for every 8 persons (or part thereof).

Critical and severe patients may be sedated and have a reduced need to access ablutions, ablution facilities proximity and provision can take this factor into account. Showers and wash hand basins should have hot and cold running water. Where possible ablution facilities must have openable windows for natural ventilation, if not possible the bathroom extraction and room ventilation system must be reviewed before admitting patient '''(see [[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|ventilation]]).'''

Portable toilets and showers may be used, provided that suitable hand wash facilities are provided. These will need to be suitably located, preferably in decentralised clusters, so that patients can easily access them without needing to walk very far. Ablutions should be located and designed in such a way as to provide visual and acoustic privacy, dignity and avoid disturbance of other nearby patients when accessing, using or cleaning the ablutions. Separate ablutions are to be provided for PUIs and confirmed patients.

====Makeshift sluice areas ====
In conventional hospital settings, sluice rooms are provided for cleaning and sanitation of soiled equipment, such as bedpans. In a temporary setting, such as an ACS, the establishment of a temporary sluice room may not be practicable, and there may not be facilities for emptying buckets, rinsing equipment etc.. The following is suggested:
Allocate a toilet, hand wash basin, not in splash range and restrict access to it for draining buckets and install a macerator for disposal of disposable bedpans. Electrical, water and waste supply points required as per supplier specification.
==== Dedicated patient treatment areas ====
The following dedicated, private spaces per ward for clinical procedures are recommended:
*Counselling and consulting room (can be shared), as shown in the figure below
[[File:Consulting room example layout.png|400px|thumb|center|Consulting room example layout]]
*Minor procedures room, as per the example provided in the figure below 
[[File:Treatment-minor procedures room example layout.png|400px|thumb|center|Treatment / minor procedures room example layout]]

== '''Logistical Services''' ==
=== Communications ===
Electronic communication should be facilitated in all zones of the ACS by the provision of device charging stations, and wifi.
=== Visitors entry point ===
Visitors are strongly discouraged from entering the ACS.
*In paediatric wards, one parent may be accommodated to visit a patient. In such cases, direct access for the visitor should be provided so that the visitor does not need to pass through the general patient area. Appropriate PPE must be donned before entering the patient area and hand washing/sanitising must be done when exiting the area.
*Non-patients who are accompanying suspected patients to the facility for testing or admission must be accommodated in a well-ventilated, spacious waiting area. Signage in such waiting areas must inform visitors about symptoms, hand hygiene and PPE.
*Hand washing/sanitizing facilities should be provided.

=== Staff areas ===
==== Staff change rooms ====
A minimum of 9m² or 4m² for a single person, increasing by one m² for each additional person is required. The clean (street side) and dirty (contaminated facility side) of the change room should be separated by a step-over barrier.

==== Staff rest areas ====
Staff rest areas within the main facility should be provided with access to kitchenette facilities and staff ablutions.
=== Staff auxiliary services ===
'''Staff on-call:'''Since staff may be required to work long hours or could be required to be on-call, shared, overnight sleeping facilities can be provided for staff on duty, outside the contaminated area, but in close proximity on the patient areas. An example is set out in the diagram below.
[[File:Example of on-call sleeping area for staff.png|center|600px|thumb|Example of overnight sleeping area for staff]]

'''Staff accommodation:''' It is advisable to provide some staff accommodation for off-duty staff who may not have suitable alternatives, for example homes too far away, transport limitations or the requirement not to expose family members to risk. This should be provided in the vicinity of the ACS, but in a physically separated zone. This amenity can be outsourced.

== '''Support Services''' ==
=== Workflow principle ===
[[File:Linen processing cycle.png|none|thumb|Linen processing cycle <ref>IUSS 2014 [https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department]</ref>]]
Progressive workflow from “dirty” (that is contaminated) to “clean” linen is advisable to reduce the risk of exposure to contaminated materials. The workflow diagram below, showing the progression from the dirty linen receiving area, to the cleaning process, to decontamination and drying, and finally sorting and packing, and storage, illustrates this principle.
=== Laboratory ===
[[File:Example of modular laboratory.png|right|thumb|Example of modular laboratory]]
The WHO recommends the following laboratory diagnostic equipment be accommodated:<ref>WHO 2020, [https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items]</ref>.
<nowiki>• Lab screening test kit
• Lab confirmation test kit
• RT-PCR kit
• Extraction kit
• Cartridges for RT-PCR automatic systems
• Swab and Viral transport medium
</nowiki>
Additional accommodation requirements are:
# Reception counter- receiving specimens
# Testing with perspex/ glass screen
# Receiving/Data capture
# Specimen holding
# Toilet - staff
# Blood storage fridge
Can be provided as a modular laboratory unit as shown in the diagram.
=== Pharmacy ===
The purpose of the pharmacy is to provide medicines needed for inpatient treatment and care.
All medical supplies should be stored in a secure, climate-controlled area in close proximity to the patient treatment area. The pharmacy must have dry, lockable, climate-controlled storage of medications. Most pharmaceuticals are labelled with storage temperatures. The pharmacy should have adequate ventilation through an openable window to prevent humidity from building up in the room. Air-conditioning or mechanical ventilation can be provided, if necessary.

Dispensing areas must be well lit. Worktop in space for stock records and administration. Dispensing counters to have perspex or glass screens to serveries. Social distancing implemented at counter, between pharmacists/assistants and between chairs in waiting area.

Can be provided in a mobile unit.

=== Radiology ===
The purpose of radiology services is to provide chest X-Ray services for COVID-19 diagnostics. In general, CT scans, bucky rooms etc. associated with some radiology equipment require specialised infrastructure and therefore is not suitable for ACS. Radiology services can be provided as a mobile floor standing unit, or containerised unit. Alternative technologies such as Lodox and hand-held ultrasound devices are being investigated as potential options and could be confirmed as suitable for use in due course.
=== Laundry services ===
All dirty linen should be handled for bagging or binning inside the patient room/cohort area. The clean linen stock should be stored conveniently close to clinical areas, in a dedicated clean area in the uncontaminated zone. Used linen should be stored in a designated, safe, lockable holding area while awaiting collection. Interim storage areas for soiled linen at the wards is allowable; this may be in dirty linen/ utility room.
Any clean linen for PUI areas should be handled in spaces physically separate from dirty linen of confirmed patient areas. It may be necessary to completely separate PUI and confirmed patient linen streams. Soiled linen and clean linen bags and bins should be dedicated and not mixed.
Full laundry cleaning and drying services may be provided on-site or outsourced. If laundry cleaning and drying services were already rendered on or for the host site before it is repurposed as an ACS, then a suitability and risk assessment should be conducted to ensure that the volumes of laundry generated and infection prevention and control measures are conducive and modifications made as necessary. A new full laundry service may take time and resources to establish, and in general, will not be established at a host site as a temporary solution. Where the site and circumstances advocate for the design of a new laundry or the upgrade of an existing laundry, the IUSS Laundry Services for Hospitals should be applied.
==== Siting and model selection considerations ====
When an existing laundry is being assessed for use or a new one is being planned the following considerations apply:
* Water and power capacity.
* Ease of access to the ACS’s main corridors and internal transport routes.
* The noise factor of the facility and its impact on nearby patient care departments.
For outsourced departments:
* Delivery areas to allow sufficient space to ensure that vehicles can manoeuvre and park easily at the reception and dispatch bays.
* Access to the ACS service roads and public roads.
==== Functional requirements ====
The most basic equipment needed in a laundry includes washing machines, tumble dryers and ironing machines. Equipment requiring steam is not recommended for a temporary facility. The sizing of the laundry, equipment and engineering services can be modified based on the principles provided in the IUSS Laundry and linen.
=== Catering services ===
Kitchenettes, that is, areas for tea, coffee and snacks, mainly for staff, in staff pause areas are discussed elsewhere in this document.
Catering services (for staff and patients) may be provided on- or off-site. If the ACS is to be established with easy access to a suitable, existing, functional kitchen service (e.g. hotel, military or hospital catering) which can meet the additional demand of the ACS, then this should be used. If there is no suitable facility, catering should be outsourced via a suitable off-site supplier. Only in the event that no feasible or suitable, existing facility or local supplier is available, should a new catering service be established at the ACS. Detailed guidance for the sizing, design and layout of catering services can be found in the IUSS Catering Services for Hospitals.
The kitchen (for on-site catering) or preparation area (for off-site catering) should be located with easy access to the point of delivery and storage of food. Adequate food and equipment storage space must be provided.
It is recommended that patient and staff meals, where provided, be supplied in disposable, containers, suitable for incineration, and that these are disposed of as risk waste immediately after use.
Where off-site catering is used, a suitable area for receiving should be provided. Space will be required for sorting meals for distribution and collecting and storing dirty dishes, washing dirty dishes, if necessary, and disposing of left-over food and disposable containers and utensils. The size of the areas required for this will depend on the number of meals delivered.

=== CSSD ===
The primary function of a Central Sterile Supply Department (CSSD) is to provide an efficient, economic, continuous and quality supply of disinfected and sterilised items, when needed, to all patient-care service points in the ACS, and to receive returned contaminated items for cleaning.
CSSD with limited sterilisation capacity (autoclave) but sufficient disinfection capacity (instrument washing). The layout requires a designated clean and dirty areas with a hard barrier between to avoid cross-over of staff and equipment. Work is unidirectional - flows from dirty – to clean - to sterile areas.
This yields three distinct zones:
1. Receiving and cleaning with pass-through windows
# Dirty receiving with Perspex or glass partitioning
# Dirty utility
# Decontamination and cleaning/wash area with throughput instrument washing
# Trolley wash/Park – external
2. Inspection, assembly and packaging with pass-through windows
# A tabletop autoclave
# Instrument washer
# Clean Packing area
3. Sterile processing, storage and distribution. (Separate issuing area from receiving area) with pass-through windows
# Store -linen and consumables
# Sterile pack store
# Issue - Collection hatch with Perspex or glass partitioning
Must also have a secure, separate receiving area for consumables receiving and storage.
An example of a CSSD unit is shown in Figure 21.T

[[File:An example of a small CSSD facility.png|600px|thumb|none|An example of a small CSSD facility<ref>IUSS 2014, https://www.iussonline.co.za/norms-standards/support-services/24-central-sterile-service-department</ref>]]

To be understood: Quality of services, eg. water (including a source of distilled or ionised water for rinsing of bronchoscopes) and electricity, quality of management, if equipment is appropriate for needs and fit for purpose, what is required of the equipment in the near and far future (relocation?), compliance with S.A. National Standards for CSSD, compatibility of equipment and devices, correct chemicals, maintenance of equipment, training of operators. Although the use of disposable breathing circuits and accessories (masks) should be encouraged, the capacity to disinfect these items if disposable is not available must be considered.

The CSSD must be sized to serve the ACS. Considerations are workload and space requirements. CFSA has extensive [https://www.fidssa.co.za/Content/Images/CFSA_SOP_2018.pdf standard operating procedures] for CSSD.

Workload: Number and type of procedures, number of procedure rooms, eg for bronchoscopy, operating hours, available inventory, volume of work and peak times, degree of mechanization, eg. manual or automated instrument washing, amount of product to be stored – chemicals, barrier wrap, chemical indicators, etc., storage and distribution records, quality records – eg. equipment checks, disposal needs.

Space requirements: Space for separation of clean and dirty, allow for unidirectional movement, allow space to manoeuvre trolleys (queue, pack/unload), reduce lifting and carrying heavy items, reduce awkward movements, allow for tidy work areas. Insufficient space will compromise sterility!

Preference should be given to construction materials and finishes which are suitable for frequent cleaning and tolerant to chemicals, including bleach (sodium hypochlorite). Impermeable flooring, non-slip and smooth washable walls are needed. Joints at walls and floors and coving at wall edge, and exposed drains should be avoided. Worktops should be sealed and should be ergonomically suitable.

Ceiling heights below 2.8m may be vulnerable to damage from humidity Where steam and moisture are generated. Noise – insulation of washer-disinfector and steriliser in technical walls will reduce noise. Lighting: Natural light if possible – windows sealed. High luminance if artificial lighting. Open, slatted shelves for sterile store area. Sinks for manual washing: At least two basins, deep (25cm at least) basins, 91 cm from floor, wide and long enough for the biggest instrument tray or container, water ports for flushing of lumens.

The CSSD space allocation and layout should be determine based on what procedures and which medical devices will be required. A typical [[equipment list is provided here]].

=== Maintenance and cleaning ===
Maintenance and cleaning services must be accommodated with offices located away from clinical areas.

=== Mortuary services ===
The National Department of Health has issued guidance on handling of dead bodies and infectious remains<ref>National Department of Health South Africa, 2020 [https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf]</ref>, which should be applied to ACS. While some guidelines have recommend that bodies of persons who have died from COVID-19 should only be held for a very brief period prior to cremation or treatment for burial<ref>Zhejiang University, 2020 [http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm]</ref>, the WHO holds the view (at the time of writing) that there is no evidence of persons becoming infected from exposure to bodies during normal ceremonial and burial activities. However, appropriate PPE should be used when handling such bodies with additional airborne precautions to be taken during autopsies<ref>WHO, 24 March 2020 [https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf]</ref>.

Either body cabinets or a refrigerated room could be used for body storage.
==== Location and layout of mortuary service ====
It is likely that not all alternative care sites will have a mortuary. Those without a mortuary must have a holding room that is located away from general access areas. This holding room must be suitably sized and conditioned. A recommended room size is 3.5 m x 3.4 m<ref>IUSS Adult Inpatient Services, 2014, [https://www.iussonline.co.za/docman/document/clinical-services/65-adult-inpatent-services-gazetted/file]</ref>
A mortuary should be located so that it is easily accessible to mortuary staff and related service providers and visitors without presenting either aesthetic, emotional or ethical problems for unrelated staff, patients or visitors. It should be separate from the general facility, allowing access for the family to view a body without passing through any potentially contaminated area of the facility. The visitors’ entrance should be external and completely separate from other access points.
Appropriate routes should be designated so that bodies are not moved through public-access areas.
==== Sizing of mortuary ====
The layout and size of a mortuary are largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.
==== Services ====
The following services are required in a mortuary:
* Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.
* Sluicing facilities are to be provided in both the body-preparation and autopsy areas if they are not a common area.
* Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush-fitted stainless steel grids.
* No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.
* The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.
* Anti-backflow devices should be fitted to the water-supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.
* Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.
==== Finishes ====
Wall and floor finishes should be impervious to liquids and easily cleanable.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Engineering and environmental controls''' ==

=== General indoor environment conditions ===

Existing environmental control systems should be modified to suit requirements in the facility. The following issues should be considered:
* Systems should be set to maximise the introduction of fresh air and maintain the pressure regime (see ventilation).
* The following internal temperature range should be maintained 19 - 24oC.
* Cooling systems should be able to cater for projected internal heat gains from people, lighting and equipment. Indicative heat gains in treatment areas are 8W/m2 from people, 15W/m2 from lighting and 3 W/m2 equipment and in critical care areas 16W/m2 from people, 15W/m2 from lighting and 60W/m2 equipment.
*As heat gain can vary widely between items of equipment, heat gain and utilisation rates for equipment should be obtained from the manufacturer to establish this more accurately.

=== Solid waste from ACS ===
According to the National Department of Health COVID-19 Environmental Health Guidelines
“All solid waste from the facility should be regarded as potentially infectious material and therefore appropriate precautions should be taken". The management of healthcare risk waste (HCRW) should follow the correct identification segregation, storage and disposal processes as indicated in SANS 10248-1.

* HCRW is segregated at the point of generation and shall be containerized to minimize the risk of contamination.
* Waste generated from patients in isolation or quarantine in a designated facility health facility is treated as health care risk waste (HCRW) as per SANS 10248-1-2008.
* The HCRW is properly packaged in a sealed, leak and puncture-proof containers/ boxes.
* The HCRW is labelled with the biohazard symbol/ sign and marked “Corona virus or COVID-19”.
* The HCRW is stored separately from other waste generated.
* The collection, transportation, treatment and disposal is provided by only an appointed/ appropriate contractor/ service provider, however, ensure that waste is safely stored until the health care waste management company can pick it up and that the company knows and acknowledges that waste was generated by suspected or confirmed COVID-19.
* The waste management company collecting must ensure that and treated and disposal is conducted at license waste treatment/ disposal facilities .
* All personnel or staff in contact with patients must be geared with appreciate personal protective equipment (PPE’s) at all times to prevent exposure or risk to health.
* Monitoring should be done at such facilities.
* All, bags, bins and boxes must be adequately sealed, as not to leak any fluids, and must be wiped down with 0.05% chlorine solution

Measures developed should consider the following.
* Develop a waste management plan following national guidelines and best practice standards for the disposal of medical waste (WHO, 2020).
* Establish procedures with medical waste service providers to regularly pick up the waste and dispose of this safely.
* Provision should be made for 5kg of solid waste per bed per day and this should be monitored and supplemented where it appears this may be inadequate.
* Ensure that access to waste is secure and controlled, for instance, by using lockable waste 1000l containers kept in a location that can only be accessed by health facility and nominated service delivery staff.
* Vermin control programs must be implemented throughout the site with HCRW collection points prioritised
* Provision for safe cleaning and disinfection of reusable containers should be provided. Cardboard, single-use HCRW boxes are removed from site and incinerated.
* Waste must not be allowed to accumulate or be stored inappropriate or unsecured containers.

== '''Engineering Services''' ==
Engineering services include patient services, ventilation, electrical power, water, medical gases, oxygen, compressed air, vacuum, lighting, and fire safety that support the needs of the patients and medical staff under normal and emergency situations. Good practice standards are provided in:
* IUSS Building Engineering Services<ref name = "IUSSBES">IUSS 2017, [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file]</ref>
* NHS Nightingale Instruction Manual<ref name="BDP2020">BDP 2020, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf]</ref>.
The guidance below draws on these and other manuals and standards. 

=== Building ventilation ===
==== Mechanical ventilation ====
While SARS-CoV-2 RNA has been detected in aerosol form, in experimental mechanical aerosolization studies, it is primarily spread through droplet and contact spread and the potential for airborne transmission is thought to be low.
However, the following advice is provided by ASHRAE regarding HVAC systems in general spaces (not specific to healthcare):
Effective high levels of ventilation must be achieved in the facility. Existing ventilation systems should be tailored to suit internal layouts and requirements and the following measures should be taken.
* Mechanical systems should be set to maximise fresh air supply to the facility. There should be no recirculated air without HEPA filtration or other validated decontamination processes.
* A pressure regime should be established, as shown in figure 2, to 'push' air from clean areas, to dirty areas and then out of the building.
* A clean air supply of over 10 L/s per person should be targeted for odour control.
* Fresh air supply shall not be located near patient beds to avoid drafts in winter.
* Extraction points can be located near patient beds in isolation wards or at a high level in long-stay wards. Short-circuiting of air between high-level supply and extraction is a performance risk in winter.
* Noise from ventilation systems and fans shall be below 45 dBA
* Protected lobbies, internal partitions, door arrangements, fans and extracts should be used to maintain the pressure regime and airflow as indicated in the diagram below.
 

[[File:Ventilation in temporary facilities.png|600px|thumb|none|Ventilation in temporary facilities<ref name="BDP2020"/>]]

==== Natural ventilation ====
The airflow direction between naturally ventilated zones may fluctuate according to the wind direction. This is not of concern within and between contaminated zones where occupants are either protected with mandatory PPE or confirmed to be infected with disease strains similar enough so as not be able to reinfect others. Where levels of occupant susceptibility to an airborne disease is significantly different, the less susceptible areas (such as PUI areas and uncontaminated areas) shall be protected from the naturally ventilated and contaminated areas by mechanical ventilation systems with a capacity sufficient to overcome the expected natural ventilation pressure fluctuations (typically 5-15Pa). Where such mechanical ventilation systems are not feasible or expected wind pressure is too great, zone adjacently must be avoided.

===Ultraviolet germicidal Irradiation===
The application of Ultraviolet Germicidal Irradiation (UVGI) for room air disinfection is well understood and is proven to be effective in the disinfection of microorganisms including M. tuberculosis (TB) in air. UVGI should, therefore, be considered as a valid element in indoor airborne infection control strategy for high volume settings. Studies have demonstrated the importance of good vertical air mixing in the room, and the safety of UVGI application. In areas where UVGI is indicated, the design and development of UVGI systems should be in accordance with the [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]<ref>van Reenen et al,2019 [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]</ref>

=== Electrical power ===
Sufficient and reliable power must be available at the facility for envisaged medical equipment, medical gases, lighting and building ventilation equipment. Power installations for the temporary facility can be divided into three zones as indicated below. These are existing services, the temporary service zone and services in each bay.
The following should be considered by competent engineering professionals.

=== Existing services ===
*Capacity: Evaluate whether sufficient power to accommodate envisaged medical equipment, additional lighting and heating, building ventilation and air conditioning can be provided. If existing capacity is insufficient, investigate if it is possible to route additional power from additional locations/transformers around the site or from adjacent sites.
* Safety: The existing electrical distribution network must be able to supply the required equipment load. If this is insufficient/appears unreliable, identify how this can be supported.
* Resilience: Evaluate back-up power and a UPS capacity against essential services demand. If existing capacity is not sufficient, source and establish temporary service capacity.

=== Temporary service zones ===
*Identify locations for temporary service zones where equipment can be located.
*Ensure that equipment and maintenance access is safe and easy.
*Ensure that all distribution boards, circuit breakers and cables are clearly labelled.
=== Services in each bay ===
*Provide pre-wired power strips/trunking as per bay requirements.
*Check that these include sufficient electrical outlets and service points for envisaged equipment.
*Ensure that trunking will carry required equipment loadings. The IUSS Building Engineering Services Guide can be used to check requirements<ref name = "IUSSBES"/>.

[[File:Layout_of_power_in_a_temporary_installation.png|600px|thumb|none|Layout of power in a temporary installation <ref name="BDP2020"/>]]
----

=== Water ===
Water points are needed for handwashing, showers and cleaning. The following issues need to be taken into account.
==== Supply ====
Onsite cold water storage, dedicated to the domestic water requirements of the facility, should be provided. A minimum usable volume of 500 litres per bed should be available.
Hot water storage and consumption should be confirmed by an engineer, as follows:
*Storage 25 L per bed.
*Consumption 180 L/bed.day W/O laundry; 250L /bed. day W laundry.

==== Handwashing ====
See infection control for clinical wash-hand basins
==== Showers ====
Showers for staff coming off shift should be available. Staff flow routes exiting contaminated treatment areas should pass through gowning and shower areas.
----

=== Medical gases, oxygen and vacuum (suction) ===
Medical gases, oxygen and vacuum services will be required in the facility. Mobile gas supply requires piping between supply and patient and clutter floor space. Preferably used fixed installations for patient rooms/cubicles, if possible.

System capacity and point of use pressures and consumption rates are to be ensured at all points. WHO provides technical guidance on [https://www.who.int/publications-detail/oxygen-sources-and-distribution-for-covid-19-treatment-centres oxygen sources and distribution]. 
[[File:Medical gas service layout.png|6oopx|thumb|Medical gas service layout<ref name="BDP2020"/>]]
The following points should also be taken into account.
* For centrally supplied medical gas and vacuum services, system resilience and availability must be ensured.
* Compressors, tanks, accumulators, VIEs, headers and controllers must be secured from uncontrolled access.
* Where possible, gas piping should be reticulated below floors or in ceilings to ensure protection from tampering, damage and ease of access.
* Where reticulation is within open areas, high-level reticulation with point-of-use droppers is advised. Low-level reticulation within rooms is to be avoided.
* Flexible piping can be used, ensuring it does not present a contamination or fire risk and should comply with local regulations. Special care should be taken with flexible O2 piping, keeping it to a minimum.
* Vacuum piping may be contaminated, where point-of-use filtration and collection systems fail. Precautions should be taken when demounting or disconnecting temporary vacuum lines.
* Ensure that oxygen pipelines are designed to provide sufficient flow to all oxygen points in the facility. In terms of utilities, oxygen and medical air would be required. A temporary vacuum point can be provided by mobile medical vacuum units distributed throughout the unit.
* Mobile medical air supplies should be considered where reaching piped specifications are not feasible. Where flexible hoses are used for oxygen and medical air special precautions need to be taken. Flexible oxygen piping must be chemically safe for O2 use. Where perishable flexible piping is used for medical air, terminal filtration at the point-of-use may be required at point-of-use. Especially for long-term use.
* Electrical and gas services can be reticulated against pipe racks or boards fixed to the bed-heads for head to head bed arrangements.
* Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.
* Gas service outlets to be labelled and colour-coded with 3mm lettering.
* SANS 7396-1 should be used to specify the requirements from design to commissioning of medical gas and vacuum systems.
* Medical gas and vacuum pipelines shall be marked per SANS 7396-1 and ISO 5359, as applicable.
* Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.
* SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.
* Plain-ended copper tubing for low-pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.
* Laboratory gas taps and valves shall be marked as described in SANS 10140-4.

=== Lighting ===
Existing lighting systems may need to be modified to suit the clinical requirements in the facility. High bay lighting presents inadequate colour rendering quality for the accurate detection or easy diagnosis of certain clinical conditions. This needs to be evaluated in the selection of supplementary lighting systems.
*Lighting levels should be provided in line with the indoor lighting levels recommended in the Table 6 of IUSS Building Engineering Services .
*Mobile task lighting systems may be adopted in the serious and critical stay wards to supplement incorrect lighting quality.
*Emergency lighting and illuminated emergency egress signage should be linked to the back-up power system.
*External security lighting in external parking areas and spaces around the building should be enhanced to ensure the security of medical staff who need to change shifts at night.

=== Fire safety ===
A functional fire alarm system should be available to support the patient care setting. Fire is a very real threat due to the possibility of an oxygen-enriched atmosphere developing so ventilation is crucial.
The use of temporary facilities for medical care should note the following fire risks (NHS, 2020):
*Patients may have a very high dependency.
*Areas are not specifically designed for patients and do not meet guidance on fire compartmentation and progressive horizontal evacuation.
*Large numbers of patients supplied with oxygen up to 10 litres per minute.
*Possibility of oxygen concentrations exceeding those generally found in the atmosphere- less risk if effective ventilation or large volume i.e. high ceilings.
* Possibility of storage, in excess of 40 litres, of alcohol-based chemicals (such as hand-rub), necessitating a flammables cabinet on site.
*Staff who may not normally work together .
*Staff who may not be familiar with the area.
*Staff not trained in fire safety, progressive horizontal evacuation or oxygen isolation for the specific area.
These factors should be taken into account in fire risk assessments which should then address significant findings in an action plan. Fire assessments should be undertaken by a qualified person and shared with operations and building management staff within the facility. Measures developed should include:
*An automatic fire detection system
*An emergency egress plans are prepared that include patients who have a very high dependency.
*Signage, notices and lighting are installed and are working effectively.
*Management processes are in place to minimise the risk of fire from ignition sources, fuels and oxygen.
*Staff are trained and a fire safety guide sheet for staff is developed and issued.
*Emergency egress routes are kept clear.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Additional Resources''' ==
=== [[Directory of Service Providers|A Directory of Service Providers can be viewed here]] ===

=='''References'''==
<references />

[[Category:COVID-19| ]]
[[Category:Alternate Care Sites|Alternate Care Sites]]

----
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19|(Return to Top)]] 
----

Infrastructure Guidance for COVID-19/Alternate Care Sites

2020-05-08T08:48:03Z

Peta: /* Spatial strategies for infection prevention and control */

[[Infrastructure Guidance for COVID-19|Return to Infrastructure Guidance for COVID-19]] 

== '''Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19'''==

This guidance work was initiated under the project titled: 
''Reducing Nosocomial and Community-Acquired Tuberculosis by Strengthening the Capacity of the South African Department of Health to Improve Implementation of Infection Control and Waste Management at All Levels of the Health System Under the President's Emergency Plan for AIDS Relief (PEPFAR)'' 

== '''Introduction''' ==
=== Purpose and approach ===
The global pandemic of COVID-19 caused by the coronavirus, SARS-CoV-2 is likely to result in a surge in need for medical care for Severe Acute Respiratory Syndrome (SARS) in South Africa. Considering the course of the pandemic in other countries, it is anticipated that South African hospitals will not have sufficient capacity to cope with the surge of persons requiring medical attention and that surge capacity via alternate care sites (ACS) will need to be established.
Surge capacity, contemplated here is not the frequent emergency department overcrowding experienced by healthcare facilities (e.g. Friday/Saturday night emergencies) or local casualty emergency that might overcrowd nearby facilities and have little to no impact on the overall healthcare delivery system. It is when a catastrophic event occurs and the affected population seek medical care from existing local healthcare facilities, causing healthcare infrastructure to become exhausted due to excess in demand. During a healthcare surge, the standard of care will shift from focusing on patient-based outcomes to population-based outcomes, and providers should anticipate “a shift to providing care and allocating scarce equipment, supplies and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals.”<ref>[https://asprtracie.hhs.gov/technical-resources/resource/491/altered-standards-of-care-in-mass-casualty-events Health Systems Research Inc., 2005]</ref> 

Surge capacity can be temporarily established in non-traditional environments, such as hotels, exhibition halls, community halls, and as field hospitals, on open spaces. 

In the context of this document, a quarantine site is a facility for patients who do not require continuous professional medical care, while an ACS is defined as a temporary facility that can provide continuous medical care for SARS. This document provides principles and considerations, high-level guidance for minimum requirements and examples for ACS. 

While an extensive set of health facility guidelines does exist<ref>[https://www.iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-servi IUSS Building Engineering Services (2017)]</ref>, these are applicable for conventional facilities and thus include services and guidelines that are not necessarily relevant to the treatment of a novel, highly infectious pathogen, with pandemic effects. Moreover, these do not provide well for the rapid and temporary establishment of facilities. 

In order to formulate high-level guidance, [[as invited by Business for South Africa]], the team reached out to professional industry bodies for inputs, in particular the South African Institute for Architects (SAIA), The Gauteng Institute for Architects (GiFA) [https://www.gifa.org.za/ Gauteng Institute for Architecture] and the [http://www.safhe.co.za/ South African Federation of Hospital Engineering (SAFHE)], by inviting input via a 36-hour research charrette. Relevant historical and contemporary literature was consulted, precedents identified and critically reviewed. An interaction with the team at Wuhan responsible for makeshift hospitals and emergency infectious diseases hospitals, Central-South Architectural Design Institute, was arranged with assistance of the Chinese Embassy. Material from the [[Infrastructure Unit System Support|Infrastructure Unit System Support (IUSS)]], international literature and guidance and input gathered from the broader architectural, engineering and healthcare professional communities was synthesised and moderated by the CSIR team. The draft was reviewed by an expert review panel. 
=== Acknowledgement of contribution ===
The contributions to the initial version of this were gratefully received. [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Acknowledgements|A list of these contributors can be viewed here.]]. 
New contributions are eagerly encouraged along with debate and discussion on the [[Talk:Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites|'''discussion forum.''']] tab above.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Scope and Assumptions''' ==
ACSs as discussed in this document are dedicated, temporary facilities for triage, testing, diagnosis, further referral and treatment of persons:
*suspected of having contracted SARS-CoV-2, (persons under investigation (PUIs)), who are symptomatic and/or are awaiting results,
*or are confirmed to be infected.
ACS will accommodate a variety of clinical, logistical, support and auxiliary services associated with the render of care. ACS will currently not be licensed to provide healthcare services. Since the ACS will operate in a non-healthcare facility, it cannot fully replace a hospital setting and its prime objective is to manage the patient load until the local healthcare system can meet demands. 

=== Exclusions ===
Quarantine facilities are accommodation facilities where a member of the community can remain for the duration of their isolation period. This is typically temporary housing for a cohort of people who do not need intensive medical attention but who cannot stay at home. Patients can take care of themselves and need limited monitoring by medical staff. Quarantine: Containing presumptive-case patients from each other and the general population.
Quarantine facilities – that is for asymptomatic persons who are in the community in self- or imposed isolation, but not displaying symptoms, or who are symptomatic, but are able to safely recover without clinical intervention and do not need continuous medical observation are not considered in this document.

=== Service regime ===
The following assumptions are made with respect to services under consideration.
* Temporary - limited to the part of the pandemic when the “conventional” hospital platform cannot meet demand. To be dismantled, thereafter.
* Uncomplicated, dedicated COVID-19 care is to be prioritised for ACS.
* Patients with comorbidities, paediatrics will be prioritised for conventional facilities, and only accommodated in ACS as a matter of last resort.
* 24 hour, 7 days a week operations. 

=== Assumed mechanism of transmission ===
Transmission of SARS-CoV-2 is understood to be from person to person firstly by [https://en.wikipedia.org/wiki/Transmission_(medicine)#Droplet_infection droplet] transmission, then by the [https://en.wikipedia.org/wiki/Transmission_(medicine)#Direct_contact contact] route and finally via airborne [https://en.wikipedia.org/wiki/Transmission_(medicine)#Airborne_airborne transmission] during or following mechanical aerosolisation. Water transmission risks are minor, occurring in special [https://en.wikipedia.org/wiki/Transmission_(medicine)#Fecal%E2%80%93oral Fecal-oral] circumstances. Reclassification of transmission mechanisms may nullify some of the approaches presented in this guidance. 

=== A call for strategic coordination ===
This document focusses on infrastructure requirements. These provisions are meaningless without staffing, equipping and resourcing. Whilst staffing, equipping and resourcing are not the focus of this document, these are likely to emerge as key constraining features. Resource constraints are likely to become acute during this pandemic. Doctors and nurses are already in critical short supply in South Africa and internationally, and are themselves susceptible to COVID-19 infection. Equipment and consumables are in short supply with heightened global demand, reduced manufacturing capacity and limits in trade flows. This necessitates strategic coordination, proactive planning, options appraisal and prioritisation. 

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Status Quo''' ==
=== Rationale and transmission status ===
According to the [https://en.wikipedia.org/wiki/World_Health_Organization World Health Organisation] (WHO), based on the largest cohort of COVID-19 patients, about 40% of patients with COVID-19 may have mild disease, where treatment is mostly symptomatic and does not require inpatient care. About 40% of patients have moderate disease that may require inpatient care; 15% of patients will have severe disease that requires oxygen therapy or other inpatient interventions, and about 5% have critical disease that requires the patient to receive mechanical ventilation. However, the evolution of the outbreak in some countries has shown a higher proportion of severe and critical cases and the need to rapidly increase surge capacity to prevent rapid exhaustion of biomedical supplies and staff. In some countries, doubling rates of cases every three days has been observed<ref>WHO-2019-nCoV-HCF_operations-2020, [https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf]</ref> 

South Africa has a high burden of disease, with a high prevalence of [https://en.wikipedia.org/wiki/HIV/AIDS_in_South_Africa HIV and TB]. Although evidence is yet to emerge of the effect of SARS-CoV-2 on a population with these pre-existing conditions, there is reason to proceed with caution<ref>The Conversation 2020, https://theconversation.com/tb-hiv-and-COVID-19-urgent-questions-as-three-epidemics-collide-134554</ref>. There is a potential direct and indirect benefit of ACS to people living with HIV and TB, as well as to general public health and the health system preservation. 

With the travel lockdown in place, and continued transmission, it appears that South Africa is on the cusp between cluster transmission and community transmission according to WHO’s classification, shown in the [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites#Key_clinical_and_infection_control_activities_for_different_transmission_scenarios_.5B3.5D|table below]], indicating that preparation should include temporary hospital facilities and mass critical care.

==== Key clinical and infection control activities for different transmission scenarios <ref>WHO 2020, [https://apps.who.int/iris/handle/10665/331492 https://apps.who.int/iris/handle/10665/331492]</ref> ====
{| class="wikitable"
|-
! !! '''No Case''' !! '''Sporadic Case''' !! '''Clusters of Cases''' !! '''Community Transmission'''
|-
| Faculty Space, Including for Transmission|| Usual Space. Enhanced Screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards). || More patient care areas re-purposed for COVID-19 within the health system, especially for severe cases || Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Staff|| Usual space. Enhanced screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards)||More patient care areas repurposed for COVID-19 within the health system, especially for severe cases||Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Supplies||
*On-hand supplies. Equip wards for COVID-19 treatment.
*Identify essential equipment and supplies, including oxygen.
*Prepare expanded local supply chain
||
*Expanded inventory of supplies with detailed protocols for use.
*Activate expanded local supply chain.
*Prepare national supply chain.
||
*Conservation, adaptation, selected re-use when safe.
*Activate contingency planning and procurement for essential equipment and supplies.
*National supply chain.
*Prepare expanded supply chain at the global level
||
*Activate contingency planning should critical equipment be in short supply.
*Determine allocation of lifesaving resources for HCWs and patients.
*Activate expanded global supply chain
|-
| Standard of Care|| Usual care with enhanced awareness and recognition of immediate needs for first COVID-19 patients|| Usual care and treatment for all patients, including those with COVID-19||Identify context-relevant core services. Shift service delivery platforms. Consider reduction in elective patient encounters, including elective surgical procedures.|| Mass critical care (e.g. open ICU for cohorted patients).
|-
| Care areas expansion|| No requirements for expansion|| Designate 10 beds per suspected COVID-19 case|| Expand COVID-19 patient care areas by a factor of 35 ||Expand COVID-19 patient care areas by a factor of 58
|}

=== Quantification of need ===
At this time there are various parallel initiatives aimed at forecasting the South African epidemic, quantifying the projected need for facilities, and a shortfall in existing capacity. At this time, there is no consensus on this. This section will be updated as further data becomes available.
ACS will prioritise mild to moderately affected COVID-19 patients where basic, targeted medical care will be provided. Should patients’ needs evolve, requiring escalation of care, then the transfer of patients from ACS sites to conventional sites of care will be needed as a matter of course, bringing with it logistical challenges and risks. In the event that the conventional hospital platform is unable to cope, ACS will have pressure to provide care for severe and critical patients, and finally for patients with comorbidity and special requirements, such as paediatrics, persons living with HIV (PLHIV), TB patients and pregnant women. The following pragmatic approach, aligned with the WHO recommended strategic approach, is suggested.
*ACS should preferably be identified with space for expansion.
*The set-up should be done so that levels of care can be upgraded to higher levels of uncomplicated care.
*A secondary upgrade for more diverse package of care may become necessary.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Strategic Approach''' ==
According to WHO, clinical interventions must be put into place immediately and then scaled up according to the epidemiologic profile.
[[File:COVID-19 Resource allocation.png|none|thumb|600px|right|WHO Strategic approach to clinical care]] 
Under this declared state of disaster, the clinical care strategy which cannot be accommodated within existing facilities, can, on a temporary basis be hosted in ACS:
*Within and around existing healthcare facilities, via reconfiguration and/or augmentation.
*In existing non-healthcare buildings suitable for repurposing, such as universities, hotels and conference centres, warehouses, gyms, hostels etc.
*On open fields, including paved parking areas with rapidly constructed, dismountable structures, such as modular tented structures or using rapid modular construction techniques. 

ACS will provide isolation, general (non-acute) care for patients with mild to moderate symptoms and as required, acute care for patients with severe symptoms. Containing confirmed-case patients from general population. Confirmed-case patients can be housed together en masse, while presumptive-case patients must be individually quarantined.
As shown in the WHO Strategic approach to clinical care, the WHO recommends a range of services to meet patient need (''Citation needed''). General (non-acute) care ACS model is designed for minimal acuity patients requiring minimal activities of daily living support (e.g. COVID-positive with minimal symptoms or require <2L of oxygen). Acute care ACS model is designed for higher acuity patients requiring closer monitoring or respiratory support (e.g. COVID-positive with pneumonia or respiratory distress requiring ventilator support). Paediatric patients are to be accommodated in separate wards, where strictly controlled visitation may be allowed. 
As a preliminary estimate, the following ratios of service is proposed:
[[File:COVID Ratios of Service.png|none|thumb|600px|center|COVID Ratios of Service]]

{| class="wikitable"
|-
! '''Case severity, risk factors<ref group="Notes"> Test suspect COVID-19 cases according to diagnostic strategy</ref><ref group="Note"> Known risk factors for severe COVID-19: age over 60 years, hypertension, diabetes, cardiovascular disease, chronic respiratory disease, immunocompromising conditions.</ref>''' !! '''Recommendations'''
|-
|Mild || Patient should be instructed to self-isolate and contact COVID-19 information line for advice on testing
and referral.
|-
|Moderate, with no risk factors ||Test suspected COVID-19 cases according to diagnostic strategy. Isolation/ cohorting in:
* Health facilities, if resources allow;
* Community facilities (e.g. stadiums, gymnasiums, hotels) with access to rapid health advice
(i.e. adjacent COVID-19 designated health post/EMT-type 1, telemedicine)
*Self-isolation at home according to National guidance
|-
| Moderate, with risk factors || Patient should be instructed to self-isolate and call COVID-19 hotline for emergency referral as soon as possible
|-
|Severe || Hospitalization for isolation (or cohorting) and inpatient treatment.
|-
|Critical|| Hospitalization for isolation (or cohorting) and inpatient treatment.
|}

=== Notes and References: ===

<references group = "Note" />
<references />

=== Typology dictates & case studies ===

[[File:NHS Nightingale Hospital London.png|thumb|NHS Nightingale Hospital London <ref name="NHS Nightingale Hospital London">Coronavirus: Building NHS Nightingale Hospital London, 2020 [https://www.bbc.com/news/in-pictures-52092253 https://www.bbc.com/news]</ref>, ]]
To meet the requirements set out in this guidance, prospective “host” sites should be carefully evaluated. The type of “host” site selected will strongly influence or dictate the choice of ACS service model.

No site is likely to meet all requirements and recommendations set out in this document. Adaptations and compromises will be necessary. Services should be provided on site where it is pragmatic to do so, for example where similar services are provided. Outsourcing can also be practical/feasible for some services, such as laboratory services, catering and laundry, provided suitable logistical arrangements can be made.

Some typological responses and service models are set out in precedent examples, shown below. The examples demonstrate that a variety of host settings are workable, provided that the appropriate utility can be contrived.

=== Pragmatic approach ===
Other than in metropolitan areas, co-location of ACS on the premises of, or adjacent to existing healthcare facilities will often be preferable because this is where intensivists and specialist clinical staffing will be available, and support services may be well established. Nevertheless, augmenting capacity at existing facilities should take into account current workloads and capacity to ensure that the COVID-19 surge disrupts normal service provision as little as possible, including continuity of care for patients with chronic conditions and TB and HIV patients. 

*'''[[Infrastructure Guidance for COVID-19/Alternate Care Sites/Case Studies|SARS ACS Precedents and Case Studies can be found here]] '''

=== Notes and References ===
<references />

== '''ACS Infrastructure Planning''' ==

=== Establishing a team ===
A planning team should be formalised to establish the minimum planning and operational requirements for the ACS and to liaise with the local community. The team should include individuals with expertise in the following areas (ideally with knowledge of healthcare delivery under emergency conditions):
*Disaster response / emergency management coordination,
*Clinical care and staffing,
*Infection Prevention and Control practitioners must be involved in all stages of planning, commissioning, in-use, and decommissioning of the facility
*Facility set-up, operations and management,
*Security,
*Transport (patient, staff),
*Engineering and project management,
*Procurement and coordination of supplies, equipment and pharmaceuticals, and
*Community liaison to ensure that concerns of the adjacent population on understood an addressed.
It is important to ensure compliance with health, safety and building regulations, by ensuring the involvement of relevant local authorities. Stakeholder engagement should be formally documented. Concerns and grievances should be systematically addressed.

=== Structural integrity and operational responsibility ===

'''Structural modifications:''' ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered. 

'''Competent person:''' All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed. 

'''Asset responsibility:''' Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented. 

'''Integrity and responsibility'''

'''Structural modifications''': ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered.

'''Competent person''': All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed.

'''Asset responsibility''': Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented.

'''Decommissioning''': Decommissioning of the facility shall be assigned to the competent person discussed above. All residual structures upon decommissioning shall comply with the National Building Regulations. Upon decommissioning, removal of equipment shall be the responsibility of the owner. An infection prevention and control practitioner should be engaged in the decommissioning phase to oversee terminal cleaning and disinfection of equipment and premises.

'''Closure''': Once all patients can be safely discharged or transported back to existing facilities for continued care and there are no ongoing healthcare surge capacity needs, the ACS can be closed. Shut down of an ACS will require decommissioning, identification of new homes or storage for equipment, and termination of ongoing contracts or arrangements. Shut down should be expedited so that the facility can quickly be returned to the control of the existing owners and returned to its usual function.

Action checklist items for ACS closure should include, but not be limited to, the following:
*conduct a site walk-through with the facility owner when shutdown activities are completed to ensure that terminal cleaning and disinfection of supplies and premises, removal of equipment and supplies, and other surge closure activities have been completed to the owner’s satisfaction.
*perform medical records storage procedures.

== '''Site Selection''' ==
When selecting a site, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital can be utilised to determine whether the site is suitable for a 100, 1000 or 2000 bed facility, as required. The following indicative minimum site sizes are needed:
*100 Bed ACS/ hospital conversion, requires ± 4 300 m2
*1000 Bed ACS/ hospital conversion, requires ± 17 600 m2
Evaluation should be done by examining plans (if available), satellite images, drone images, scans and by physical inspection (walkabout). A comprehensive photographic survey should be undertaken and retained for record purposes on the site inspection. This will serve as an audit record and may assist in returning the site to its original function on ACS decommissioning and closure. When scrutinising documents and conducting site inspections to confirm the suitability of a site to host an ACS, the following criteria should be taken into account.
=== Criteria ===
*Affordability (costs, including operational costs known and budget identified),
*Sufficient physical space and capacity to house the immediate need, with the potential to accommodate physical space requirements. For example, open site should not be sloping,
*Legal rights and encumbrances, including renewal opportunity,
*Good access to highway and main roads,
*Well secured perimeter and limited controlled access points,
*Proximity to other hospitals and care sites,
*Accessibility for key staff and public transport,
*Good vehicular access around the site to set up temporary equipment such as back-up generators,
*Free from clear and present danger,
*Outside attenuation zones, floodplains,
*Outside high wind zones,
*Structure in good repair,
*Effective onsite facilities management team who understand how systems work,
*Potential for expansion, if required,
*Access to sufficient capacity for
**potable water,
**adequate sewage,
**telephone,
**internet access with sufficient bandwidth,
**electricity,
*A zone for cleaning, disinfection, and decontamination of equipment at least 15 metres away from occupied areas with access to water, a hard impervious surface and drying areas in the sun, with runoff discharge into the sewer and not into marine ecosystems or the environment. Include area for cleaning and storage of cleaning equipment.
*Likelihood of acceptance of hosting an ACS by the adjacent and local community

=== Desirable ===
*Durable, cleanable surfaces,
*Large open spaces that can be converted to accommodate temporary structures,
*Good ventilation,
*On-site kitchen and laundry,
*Housekeeping staff (chemical and equipment storage, lockers, rest facility, administration office),
*Space conducive for staff respite area and locker rooms,
*Amenities with universal access,
*Fire protection safety and equipment,
*Elevator access for patients if the building has more than one floor,
*Capacity for expansion, and
*Accessible to at least two roadways to provide continued access in the event that one roadway becomes blocked on inaccessible.

== '''Infection Prevention and Control''' ==
General guidance for COVID-19 [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|Infection Prevention and Control]] can be accessed [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|here]] 

Infection prevention and control in the context of COVID-19 should respond to transmission routes of primary concern for the pathogen of interest (droplet and contact transmission, and management of risk waste) as well as infection risk of a general nature (water and sewerage, airborne transmission – under high TB/HIV burden, and general waste).
In addition to satisfying [https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html standard precautions for all patient care], transmission-based precautions should focus on three pillars: exposure reduction by spatial configuration, operational strategies, and personal protection.
=== Transmission-based precautions ===
'''Droplet and contact spread''': Transmission of SARS-CoV-2 virus occurs via droplet and contact spread. The virus has been shown to persist on surfaces for extended periods of time and is known to be efficient at infecting people. 

'''Medical waste and linen:''' As SARS-CoV-02 is carried in body fluids and faecal matter, disposal of contaminated items (tissues) and cleaning regimes (spaces, garments, linen) should be accommodated carefully in the workflow design and infrastructure provision. A site-specific waste management plan should be formulated in accordance with a site-specific waste management plan with reference to SANS 10248. 

'''Airborne transmission:''' Under exceptional circumstances, the risk of airborne transmission arises for SARS-CoV-2, as detailed below.
{| class="wikitable"
|-
!Airborne Transmission Risk Factors
|-
|
As SARS-CoV-2 is not considered airborne, respiratory protection against airborne transmission is not considered necessary, except where aerosolisation of particles may be a risk.
According to the CDC
*tracheal intubation,
*non-invasive ventilation,
*tracheotomy,
*cardiopulmonary resuscitation, or
*manual ventilation before intubation and bronchoscopy.
According to doctors in the field also when performing
*COVID-19 diagnostic sampling as patients can be induced to cough and sneeze.
*Suspected or confirmed comorbidity of TB is not an additional risk where correct COVID-19 PPE is applied.

|}
South Africa has a high prevalence of TB and HIV, and therefore, although the risk of COVID-19 transmission via the airborne route is not paramount, there is a high likelihood that undiagnosed TB infectious patients may present at the ACS for treatment. TB triage may be challenging in the ACS as there are symptoms in common (coughing) with COVID-19. This country-specific risk is taken into account in this guidance

=== Additional precautions ===
'''Water and sewerage contamination:''' The International Water Association [[Infrastructure Guidance for COVID-19/Alternate Care Sites/COVID-19 A Water Professionals Perspective|concluded]] that water and sewerage contamination is not considered to be a key risk factor for COVID-19. The panel expressed concern for “how waste and specifically wastewater (medical) would be handled by places (e.g., hostels, hotels) that are used to serve as interim COVID-19 quarantine or testing facilities or accommodation ([ACS]. These are places other than hospitals that are used in the interim for such purposes and do not usually handle wastewater from medical settings. Such facilities should be monitored carefully.” 

== '''Spatial Strategies for Infection Prevention and Control''' ==

=== Restricted access and zone control ===
The site will be arranged to establish clear zoning, with a clear restricted zone protocol and access protection. Zones should be deemed to be "contaminated" or "uncontaminated" with clear transition areas between them.

; Contaminated zones
: (also known as "dirty areas") are areas occupied by COVID-19 infected persons, PUIs, equipment, materials and supplies which have come into contact with such persons without yet undergoing a decontamination procedure. These areas will include patient ward areas and ablutions, patient admissions (including ambulance drop-off) and the associated clinical areas. Staff rest and dining facilities should be outside the contaminated zone. Limited stock for immediate use should be kept in the contaminated zone. Layout designs should consolidate contaminated zones as far as reasonable, and avoid uncontaminated zones as islands in contaminated zones.

; Uncontaminated zones
: (also known as "clean areas") are areas not generally occupied by PUIs or confirmed COVID-19 infected persons. Equipment, materials and supplies in these areas have not yet come into contact with contaminated zones or have undergone a decontamination procedure. These will include clinical management planning rooms, stock rooms, bulk stores, pharmacy, laboratory areas, kitchen and laundry.

; Transition zones
: (also known as intermediate zone) are the spaces through which transfer of people and goods from uncontaminated to decontaminated zones, and vice versa, occur. Materials from the contaminated zone should be decontaminated or contained in the transition zone. The transfer of goods and persons should be highly ritualised and, as far as possible, traffic across transition zones should be minimised. Transition areas should be strategically located to serve this function. Separation of in-going and out-going transfer of goods and persons is preferable. Transition areas include ambulance, trolley decontamination, CSSD, laundry and waste bagging areas, patient locker area and staff change areas with spaces for donning and doffing of PPE.

=== Site layout and master-planning ===
Spatial configuration and layout can ensure unnecessary cross-over of function is avoided. This entails the systematic separation of functions and the managed transition between activities to facilitate consistency of care, an orderly, efficient work environment, less waste and reduced risk for improved outcomes. To achieve this, functional relationships should first be considered at the site level before being considered at the building level. 

<gallery mode=packed heights=300px style="text-align:left">
Layout for a SARS facility, clustering functions with minimised cross-over.png|center|thumb|Layout for a SARS facility, clustering functions with minimised cross-over <ref name="Layout1">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Layout_for_a_Patient_cohorting_strategy.png|center|thumb|Layout for a Patient cohorting strategy <ref name="Layout3">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Tygerberg Hospital virus triage unit site layout.png|center|thumb|Tygerberg Hospital virus triage unit site layout <ref name="Western Cape Provincial Government, 2020a">Western Cape Provincial Government, 2020 a</ref>
</gallery>

The WHO's Clustering Layout <ref name="Layout1"/> and Tygerberg Hospital virus triage unit<ref name="Western Cape Provincial Government, 2020a"/> show worked examples of building and site layouts, which are configured with these principles, respectively. '''Cohorting''' is defined as clustering patients with similar or compatible clinical needs together for risk reduction, acuity, efficiency and quality management, as illustrated in WHO's Cohorting Layout <ref name="Layout3"/>

=== Workflow ===
Within individual functional zones, the workflow activities can be arranged to proceed from clean procedures to contaminated procedures. In the example below, the staff arrival, PPE donning, doffing and patient flows are worked to have controlled interaction and minimised cross-over

<gallery mode=packed heights=400px >
ACS HCW Flow.png |ACS Health Care Worker Flow
COVID-19 Workflow in small unit.png |COVID-19 Workflow in Small Testing Unit <ref name="Western Cape Provincial Government, 2020b>Western Cape Provincial Government, 2020 b</ref>
COVID-19 Workflow in large unit.png |COVID-19 Workflow in Large Testing Unit <ref name="Western Cape Provincial Government, 2020b"/>
</gallery>

As far as possible, a single direction flow of clean to dirty is recommended for all processes: support services, supply and waste.
The Small ACS unit workflow diagram<ref name="Western Cape Provincial Government, 2020b"/> illustrates the recommended separation of access and exit, separate waiting seats, for persons who may be COVID-19 infected. Separate spaces are provided for donning and doffing PPE. Staff change areas are provided.

In the Large ACS unit workflow diagram <ref name="Western Cape Provincial Government, 2020b"/>, there is a clear separation between staff areas and patient areas. Waiting seats are set far apart to reduce transmission risk. Staff change rooms are provided near the point of entry to the facility for staff to change from street clothes into medical work clothes. To prevent work clothes worn inside the facility from contaminating street clothes, these are kept in separate lockers. A step-over barrier from dirty to clean sides of the change room is helpful to enforce a mind-set of avoiding cross-contamination. Bins for contaminated garments are to be provided in change rooms. Shower facilities are to be provided for staff.

== '''Operational Strategies''' ==
=== Cleaning, disinfection and decontamination ===
Surface and substrate specification, and detailing of all areas should, as far as possible, allow for frequent:
*Cleaning with detergent and water.
*Disinfection with 75% alcohol solution (metal surfaces).
*[https://en.wikipedia.org/wiki/Sodium_hypochlorite Sodium hypochlorite] (1,000 ppm)/ Household bleach.
*Disinfectants listed on the EPA List N<ref>The United States Environmental Protection Agency, [https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 List N: Disinfectants for Use Against SARS-CoV-2 (Last Visited 2020) ]</ref> (for non-critical environmental cleaning).
*High-intensity ultraviolet surface disinfection (UV-C).
*Decontamination and sterilisation of clinical equipment.

=== Goods and waste management ===
Remove any unnecessary furniture, equipment and paraphernalia from all patient care and clinical areas. Provide a clear, secure space for waste management. Any potentially infectious waste materials generated at the ACS should be considered and treated as medical waste (health care risk waste). The applicable legislation is:
*[https://www.gov.za/sites/default/files/gcis_document/201409/35405gen452.pdf The National and Provincial Health Care Risk Waste Management Regulations].
*[https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf National Department of Health COVID-19 Environmental Health Guidelines.]<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>
Waste disposal bins should be positioned near the exit inside each patient rooms or wards to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another patient in the same room.

=== Materials and finishes ===
Floor materials must be:
*Level,
*Free of dust and oil,
*Impervious and smooth,
*Slip-resistant in wet areas (e.g. patient ablutions).
Smooth, cement screed floors are acceptable. Where hosting facilities have carpeted areas, a risk assessment of factors such as durability, hygiene and decontamination needs to be conducted. In cases where the acceptance of carpeted flooring is contradicted (but other factors make it a compelling option), temporary floor finishes or covering can be investigated.

== '''Personal protection''' ==
=== Hand sanitation ===
Where wash-hand basins are not provided, clinical wash-hand basins should be installed, at the minimum rate of provision of one wash-hand basin per 5 beds. Clinical wash-hand basins (see figure below) have a variety of features not present in standard wash-hand basins, which are preferable for infection prevention and control. Where standard wash-hand basins are provided, an upgrade is not necessary. In all cases, there should be no surfaces and no clutter, equipment or supplies in the vicinity of wash-hand basins, including surgical gloves.
<gallery mode=packed heights=400px>
Clinical hand wash basin.png|Handwash Basin <ref>de Jager 2020</ref>
Portable Wash-hand Basin.png|Portable wash hand basins can be provided in ACS <ref name="BDPa">BDP 2020, NHS nightingale instruction manual, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf</ref>
</gallery>

Where wash-hand basins are not available, portable units can be used, as shown above<ref name="BDPa"/>. Mounted brackets for hand sanitisers are to be provided for every two beds, preferably mounted near the foot rather than the head of the bed and at all common touch points such as entry points at ablution facilities, linen room, sluice, storerooms, medicine rooms/cupboards, near refrigerators, telephones, light switches, at entry/exit doors, etc.

=== Personal protective equipment ===
Donning and doffing points for personal protective equipment, and convenient, safe disposal of consumables to be placed at critical key points when entering patient areas.
----

== '''General transmission mitigation''' ==
=== Water and sanitation ===
To comply with National Building Regulations; Hazardous Biological Agents Regulations and National Department of Health COVID-19 Environmental Health Guidelines<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>.

=== Droplet aerosolisation ===
When designating areas for procedures during which aerosolization and airborne transmission risk is high, the building ventilation must be carefully considered to take into account downstream risks. In particular, consider to where potentially contaminated air, arising from aerosol-generating procedures, is exhausted. In general, air exhausted directly to the outside is diluted and considered safe, unless there are openings to occupied spaces near the exhaust air outlet. 

In the event that potentially occupied spaces will receive partially diluted or undiluted contaminated air, or where this is indeterminate, the aerosolising activity should be designated to an alternate area. In the event that an alternative is not available, some treatment regime (air filtration or air disinfection) is necessary. 

In most naturally ventilated settings, the airflow direction between zones may fluctuate according to the wind direction. Such high-risk spaces should not be adjacent to spaces with high susceptibility rates, such as PUI areas and uncontaminated areas. Contaminated areas should not be directly adjacent to clean areas unless mechanically ventilated. 
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|Guidance on COVID-19 building ventilation design is provided here]].

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Health, Safety and Well-being''' ==
In addition to the infection prevention and control measures discussed above, the following should be provided for health, safety and well-being.
=== General provisions ===
*Minimised and controlled entry and exit points, with suitable control.
*Clearly identified accessible and marked routes for patients, staff, goods and waste.
*Clear designation of restricted zones.
=== Site level provisions ===
*Safe staff parking and arrival of staff via planned and public transport.
*Clearly demarcated parking for people with disabilities.
*Arrival and departure point for patients via public transport, passenger vehicles, and emergency service.
*Limited safe patient parking.
*Supply of goods and removal of waste.

=== Within and between buildings ===
*Entrances with a clear opening width (CoW) of at least 900mm.
*Routes with a minimum width of 2 000mm free of hazards, for example, rubbish bins.
*All clinical, patient and support areas to be accessible by trolley.
'''Ramps''' should be of stable construction, capable of sustaining a mass of 300kg. They should incorporate side lips and the surface should be slip-resistant. Gradients should be as gentle as the circumstances allow. (Recommended maximum 1:20). 
'''Small changes in floor levels''' are not desirable, but where these exist are to be clearly marked with reflective paint/ tape, and lit at night
Elevators between different floors, where patients need access (The recommended minimum lift size for patient trolley/stretcher movement is 1 400mm × 2 400mm, however, this may not be possible). 
'''Pathways''' to be lit at night, where used at night. 
'''Staircases''' must be well-lit at night with non-slip surfaces and secure balustrades. 
'''Doors''', Double doors and automated or push-operated doors to all clinical areas are to be preferred, where these are newly installed or able to be retrofitted. Door closers are to be disabled, where not necessary to reduce touch surfaces. Hand sanitisers to be provided at where high touch common surfaces occur (e.g. wall-mounted at doorways).

=== Signage ===
The appropriate level of information to facilitate legibility, orientation and wayfinding. Minimum standards, signage to be:
*Clearly visible, simple font, font size, contrasting colours, placed in the field of vision
*Washable
*Comprehensive safety signage - fire signage (exits, equipment etc.)
*Restricted areas clearly marked
*Identification signage - each patient space to be allocated a unique number and a whiteboard or perspex sheet for writing the patient’s name
Signs should be posted immediately outside of patient rooms indicating appropriate IPC precautions and required personal protective equipment (PPE).
Signage of a temporary nature can be provided on laminated white A4 sheets attached eye-level. The text should be black sans-serif (for instance Arial) text at least 40point size and centrally positioned on the sheet. Detailed guidance on signage is provided in IUSS Inclusive environments.
=== Safety and security ===
Upon identification of the ACS host site, a team should be convened to conduct a multidisciplinary safety and security analysis. These critical team members need to form the working committee responsible for undertaking the detailed assessment of the existing facility’s security. They should analyse data about the security system’s condition and review existing security concerns or issues that are reasonably likely to become concerns in the near future. The figure below represents a five-zone approach to security, which is a recommended, systematic approach to security.
[[File:Zonal approach to security.png|center|600px|thumb|IUSS Security- Zonal Approach to Security <ref name="IUSS Security">IUSS Hospital design principles - Security [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file]</ref>]]
The security strategy should take into account that whilst clinical services and some logistical and support services will be required 24 hours a day, seven days per week, some support services, logistics services and auxiliary services may only be operational for the minimum periods required to meet demand. These functional elements should be capable of being secured, for example over weekends and at night, as the case may be.
Detailed guidance is available in [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file IUSS Hospital design principles - Security] <ref name="IUSS Security"/>

=== Comfort and dignity ===
Supplemental heating: Patient health and comfort are dependent on, amongst others, maintaining body temperature. The ACS structural technology must be selected to achieve the general indoor environment conditions discussed in a subsequent section for all clinical and occupied areas. As we are moving into South African winter supplemental heating may be required, especially in the evenings, in order to avoid hypothermia. Use of fans, bar, radiator or gas heaters should be prohibited. Unless clinical areas can be maintained above 18 degrees centigrade, patients should each have an infrared heater available, in addition to blankets. Personal/ donated blankets can be considered if they are laundered first and could be destroyed upon discharge.
Mobile screens should be available to provide privacy where necessary (e.g. during consultations or procedures).
<gallery mode = packed heights = 400px>
Bed_Isolator_-Vietnam.png|thumb|Flexible Barrier Isolator<ref>WHO. (2020), Severe Acute Respiratory Infections Treatment Centre. Geneva, Switzerland : WHO- World Health Organization</ref>
ACS Cohort beds.png|ACS Cohort beds.png|thumb|Excel Centre London 04-2020 <ref>Architects' Journal 2020, [https://www.architectsjournal.co.uk/news/nhs-nightingale-bdp-on-the-first-nine-days-converting-the-excel-centre/10046749.article https://www.architectsjournal.co.uk/news]</ref>
</gallery>
Some solutions which address patient privacy and dignity are depicted above.

=== Notes ===
<references/>

== '''Schedule of Accommodation''' ==
Based on clinical needs of the ACS, a schedule of accommodation can be crafted capturing the clinical, clinical, logistical, support and auxiliary services associated with the render of care. When deriving a schedule of accommodation, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital tool can be used. Functions to be accommodated are: 
'''Clinical services''': Triage, rapid assessment of persons entering the facility, to expeditiously identify and render the appropriate service. Admissions and registration. Inpatient accommodation is to be organised according to cohorting principles, discussed above. Testing and diagnostics, including laboratories and x-ray. Safe storage and dispensing of drugs to patients.Offices for clinical administration and clinical planning meeting rooms in the clean zone are needed. 
'''Logistical services:''' Logistical services will entail management of flows of people, goods, services and information to and from the site, as well as within the site. It includes security and communication arrangements. Staff entry, preparations to transition from outside to clinical work environment, including pause areas for relief. Emergency services, visitors. Goods, supplies and storage and waste removal and/ or treatment.
Support services key to the provision of clinical services should be separated so that the risks associated with that particular activity can be managed. 
'''Support services are:'''
*Laboratory services
*Catering
*Laundry
*Environmental cleaning and housekeeping
*CSSD
*Maintenance and cleaning of surrounds, eg. waste areas
*Porters/”runners”, stretchers/wheelchairs
*Mortuary
* Security
Support services can be provided off-site, in which case, safe, secure and efficient transfer and logistical arrangements should be designed. 
'''Auxiliary services:''' Auxiliary services are services which may be provided on or near the ACS site, but which are not directly related to core clinical care. This included overnight accommodation for staff who may not wish to return home to avoid exposing their families, or who need rest between shifts, or for discharged patients awaiting transport home, volunteers who have recovered from SARS-CoV-2.
Limited psychosocial services and allied health services may also be provided on or near ACS for example by approved partners.
Examples of schedules of accommodation for patient and support spaces for a protective isolation ward is available [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedule for COVID-19 Isolation Wards|here]] and mild to severe cases [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedules for COVID-19 Wards for Mild to Severe Cases|here]].

== '''Clinical Services''' ==
=== Triage ===
Confirmed COVID-19 cases and PUIs who are referred from a testing facility or a higher level of care, will enter the facility in a triage area to receive vital screening and initial assessment. They will be registered and admitted to inpatient care. They will be assigned a "ward" or section of the facility - based on disease status and acuity. These are Protective Isolation, the Mild & Moderate ward, or the Critical & Severe wards. Patients should be clustered according to gender. As far as practicable, ablutions for each gender, isolation patients, paediatrics and staff shall be separately provided. Paediatrics patients, if admitted, are to be assigned a dedicated section.
As patients recover or deteriorate, they may be relocated to the appropriate section/ ward.
Once the patient has sufficiently recovered and a negative test result is received they will be appropriately decontaminated and discharged, collecting medication from the dispensary on exit. Patient movement between various sections of the ACS will be restricted as far as possible, with mobile radiology units, in-ward medication dispensing and in-ward food service.

=== Inpatient ACS accommodation ===
Separate spaces for:
*suspected, unconfirmed cases, under observation (PUIs), to be accommodated in isolation facilities (separate rooms, if possible);
*patients with confirmed COVID-19 with mild to moderate disease, not requiring dedicated oxygen therapy;
*patients who require dedicated oxygen therapy;
*patients requiring mechanical ventilation; and
*recovered/ confirmed negative.
==== Protective Isolation Facilities ====
Suspected, unconfirmed cases, under observation – persons under investigation (PUIs) to be accommodated in protective isolation facilities (separate positive-pressure rooms, if possible). PUI are restricted to their rooms. All food and laundry services will be brought to the PUI rooms to reduce interaction and potential contamination. All waste will be collected by facility staff and taken to waste handling areas. Infection prevention and control measures are put in place for the handling of used food utensil and laundry as well as waste collection. PUI areas will have restricted access, including for staff serving other inpatient sections, for confirmed cases.

==== Inpatients accommodation for confirmed COVID-19 ====

Inpatient facilities confirmed positive COVID-19 can be accommodated in large shared ‘wards’ with partitioning between patients. Partitioning between patients is optional. Partitioning is preferable to curtains found in conventional hospitals, as they are more conducive to daily cleaning. If curtains are used, antimicrobial treated fabrics with biocide used to treat the curtains has been tested to international standard EN 14476 and shown to be effective against H1N1 Influenza A Virus (Swine Flu), >99.999% kill rate in 5 minutes and measles morbillivirus, >99.99% kill rate in 5 minutes are preferred. If only separate rooms are available, patient monitoring and surveillance will need to be accommodated. This phase of treatment has a lower area/space requirement compared with PUIs, as cross-infection between patients is less of a concern. Shared ablution facilities are acceptable. It is recommended that, at least, two general accommodation ward areas be provided. 

a) Mild and moderate patients, and 
b) Serious and critical patients. 

The room must have openable windows for natural ventilation if a dedicated positive pressure ventilation system is not available. Ducted ventilation systems shall not be shared between PUI areas and confirmed COVID-19 patient areas. 
[[File:COVID-19 ACS - protective isolation – bed layout.png|thumb|center|800px|ACS - protective isolation – bed layout]]
[[File:COVID-19 ACS – mild-moderate patient bed layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient bed layout]]
[[File:COVID-19 ACS – mild-moderate patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient shared ward layout]]
[[File:COVID-19 ACS – severe-critical patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – severe-critical patient shared ward layout]]

Examples above show bed layout with bed spacing for protective isolation, a mild/moderate patient and a mild/moderate patient shared ward and for a severe/critical patient

=== Patient services ===
Patients in ACS will not generally be ambulatory and will be confined to their room, or cubicle in a bed. In general, domestic beds or hospitality industry (hotel) beds are not suitable for patient care. These should only be used where a hospital-grade bed cannot be sourced, as hospital beds are designed for ease of cleaning and decontamination (for infection prevention and control) and with patient and ergonomics, safety and comfort taken into account (they prevent back injury for nursing staff and can help to prevent bedsores). The higher the specification of bed, the more suitable it is for the higher levels of care. Lockers for patients personal belongings should be provided in the uncontaminated zone (in which case bedside lockers will not be necessary), and it is preferable (where bedside lockers are not provided) for overbed tables to be provided, per bed, if possible. 
The following beds are suitable:
*Repaired and refurbished beds from condemned hospital stocks.
*South African National Standard, SANS 521:2013 Edition 3.5, on Hospital beds and cots ISBN 978-0-626-28830-3.
*Beds listed on the National Treasury (See [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Hospital Bed Specification|specification]]).
The table below details the minimum services required at each patient bed. Details on these services are discussed in a subsequent section of the document.

{| class="wikitable"
|-
! Service/ Capacity!!Triage!!Isolation !!Mild – moderate inpatient!!Severe case wards!!Critical case wards
|-
| Power – 16A 230V Single socket outlet||As needed ||1 per bed||1 per bed||3 per bed||6 per bed
|-
| UPS Power – 16A 230V Single socket outlet ||As needed||1 per bed||1 per bed||1 per bed||2 per bed
|-
| Medical Air<ref group="Note">Mobile units recommended for intermittent use. 3 per 20 beds</ref><ref group="Note">There are some ventilators which have built-in compressors allowing them to function without Medical Air. This is however, not the norm. With Ventilators probably being the most difficult medical device to obtain at present, it would be prudent to rather allow for Medical Air at each bed.</ref> (LP)400kPa||No||Yes||No||Yes||Yes
|-
| Medical O2 -400kPa||Portable/shared||Portable/shared||No||One||Two
|-
| Vacuum-40kPa||No||Portable/shared||Portable/shared||Yes||Yes
|-
| Equipment rail||||||||Yes||Yes
|-
| Upper room UVGI||Optional||Optional||||||Optional
|-
| Examination light||No||No||Yes||Yes||Yes
|-
| Room Ventilation rate||60 L/s per person||10 L/s per person||10 L/s per person||10 L/s per person||12 ACH
|}
'''Notes: '''
<references group="Note" />

Two additional 16A 230V single socket outlets, one two-pin outlet and a worktop should be provided for every 32 beds (or part thereof), for:
*Electrocardiograph (ECG): Could be omitted if monitors have a full 12 lead ECG function.
*Blood gas analyser: Could be omitted if a Lab Services are available.
*Staff cellphone charging.

Example of healthcare technology to be provided for critical care patients is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]. Severe patients may be provided continuous positive airway pressure (CPAP). Emergency trolleys (“crash carts”) are to be provided in patient areas with convenient access to patient beds, out of the passage of corridors and is moved to the patient when needed. 1 crash cart for every 16 patients (or part thereof, with at least one dedicated for PUIs. An example of provisions for a crash cart is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]
==== Patient ablutions ====
[[SARS-CoV-2 is found in faecal matter]], so careful management of patient body fluids is crucial and convenient, practical support for frequent cleaning of ablutions especially shared ablutions is necessary. Dedicated ablutions (toilets and showers) are to be provided for patient use. Toilets and showers should be in separate rooms.
Hand washbasins and or/ hand sanitiser should be provided both inside and outside the toilet room so that patients can wash their hands on the way in and on the way out of the room.
*1 toilet for every 8 persons.
*1 shower for every 8 persons.
*1 disabled ablution for every 8 regular ablutions (or part thereof).
*1 disabled shower for every 8 persons (or part thereof).

Critical and severe patients may be sedated and have a reduced need to access ablutions, ablution facilities proximity and provision can take this factor into account. Showers and wash hand basins should have hot and cold running water. Where possible ablution facilities must have openable windows for natural ventilation, if not possible the bathroom extraction and room ventilation system must be reviewed before admitting patient '''(see [[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|ventilation]]).'''

Portable toilets and showers may be used, provided that suitable hand wash facilities are provided. These will need to be suitably located, preferably in decentralised clusters, so that patients can easily access them without needing to walk very far. Ablutions should be located and designed in such a way as to provide visual and acoustic privacy, dignity and avoid disturbance of other nearby patients when accessing, using or cleaning the ablutions. Separate ablutions are to be provided for PUIs and confirmed patients.

====Makeshift sluice areas ====
In conventional hospital settings, sluice rooms are provided for cleaning and sanitation of soiled equipment, such as bedpans. In a temporary setting, such as an ACS, the establishment of a temporary sluice room may not be practicable, and there may not be facilities for emptying buckets, rinsing equipment etc.. The following is suggested:
Allocate a toilet, hand wash basin, not in splash range and restrict access to it for draining buckets and install a macerator for disposal of disposable bedpans. Electrical, water and waste supply points required as per supplier specification.
==== Dedicated patient treatment areas ====
The following dedicated, private spaces per ward for clinical procedures are recommended:
*Counselling and consulting room (can be shared), as shown in the figure below
[[File:Consulting room example layout.png|400px|thumb|center|Consulting room example layout]]
*Minor procedures room, as per the example provided in the figure below 
[[File:Treatment-minor procedures room example layout.png|400px|thumb|center|Treatment / minor procedures room example layout]]

== '''Logistical Services''' ==
=== Communications ===
Electronic communication should be facilitated in all zones of the ACS by the provision of device charging stations, and wifi.
=== Visitors entry point ===
Visitors are strongly discouraged from entering the ACS.
*In paediatric wards, one parent may be accommodated to visit a patient. In such cases, direct access for the visitor should be provided so that the visitor does not need to pass through the general patient area. Appropriate PPE must be donned before entering the patient area and hand washing/sanitising must be done when exiting the area.
*Non-patients who are accompanying suspected patients to the facility for testing or admission must be accommodated in a well-ventilated, spacious waiting area. Signage in such waiting areas must inform visitors about symptoms, hand hygiene and PPE.
*Hand washing/sanitizing facilities should be provided.

=== Staff areas ===
==== Staff change rooms ====
A minimum of 9m² or 4m² for a single person, increasing by one m² for each additional person is required. The clean (street side) and dirty (contaminated facility side) of the change room should be separated by a step-over barrier.

==== Staff rest areas ====
Staff rest areas within the main facility should be provided with access to kitchenette facilities and staff ablutions.
=== Staff auxiliary services ===
'''Staff on-call:'''Since staff may be required to work long hours or could be required to be on-call, shared, overnight sleeping facilities can be provided for staff on duty, outside the contaminated area, but in close proximity on the patient areas. An example is set out in the diagram below.
[[File:Example of on-call sleeping area for staff.png|center|600px|thumb|Example of overnight sleeping area for staff]]

'''Staff accommodation:''' It is advisable to provide some staff accommodation for off-duty staff who may not have suitable alternatives, for example homes too far away, transport limitations or the requirement not to expose family members to risk. This should be provided in the vicinity of the ACS, but in a physically separated zone. This amenity can be outsourced.

== '''Support Services''' ==
=== Workflow principle ===
[[File:Linen processing cycle.png|none|thumb|Linen processing cycle <ref>IUSS 2014 [https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department]</ref>]]
Progressive workflow from “dirty” (that is contaminated) to “clean” linen is advisable to reduce the risk of exposure to contaminated materials. The workflow diagram below, showing the progression from the dirty linen receiving area, to the cleaning process, to decontamination and drying, and finally sorting and packing, and storage, illustrates this principle.
=== Laboratory ===
[[File:Example of modular laboratory.png|right|thumb|Example of modular laboratory]]
The WHO recommends the following laboratory diagnostic equipment be accommodated:<ref>WHO 2020, [https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items]</ref>.
<nowiki>• Lab screening test kit
• Lab confirmation test kit
• RT-PCR kit
• Extraction kit
• Cartridges for RT-PCR automatic systems
• Swab and Viral transport medium
</nowiki>
Additional accommodation requirements are:
# Reception counter- receiving specimens
# Testing with perspex/ glass screen
# Receiving/Data capture
# Specimen holding
# Toilet - staff
# Blood storage fridge
Can be provided as a modular laboratory unit as shown in the diagram.
=== Pharmacy ===
The purpose of the pharmacy is to provide medicines needed for inpatient treatment and care.
All medical supplies should be stored in a secure, climate-controlled area in close proximity to the patient treatment area. The pharmacy must have dry, lockable, climate-controlled storage of medications. Most pharmaceuticals are labelled with storage temperatures. The pharmacy should have adequate ventilation through an openable window to prevent humidity from building up in the room. Air-conditioning or mechanical ventilation can be provided, if necessary.

Dispensing areas must be well lit. Worktop in space for stock records and administration. Dispensing counters to have perspex or glass screens to serveries. Social distancing implemented at counter, between pharmacists/assistants and between chairs in waiting area.

Can be provided in a mobile unit.

=== Radiology ===
The purpose of radiology services is to provide chest X-Ray services for COVID-19 diagnostics. In general, CT scans, bucky rooms etc. associated with some radiology equipment require specialised infrastructure and therefore is not suitable for ACS. Radiology services can be provided as a mobile floor standing unit, or containerised unit. Alternative technologies such as Lodox and hand-held ultrasound devices are being investigated as potential options and could be confirmed as suitable for use in due course.
=== Laundry services ===
All dirty linen should be handled for bagging or binning inside the patient room/cohort area. The clean linen stock should be stored conveniently close to clinical areas, in a dedicated clean area in the uncontaminated zone. Used linen should be stored in a designated, safe, lockable holding area while awaiting collection. Interim storage areas for soiled linen at the wards is allowable; this may be in dirty linen/ utility room.
Any clean linen for PUI areas should be handled in spaces physically separate from dirty linen of confirmed patient areas. It may be necessary to completely separate PUI and confirmed patient linen streams. Soiled linen and clean linen bags and bins should be dedicated and not mixed.
Full laundry cleaning and drying services may be provided on-site or outsourced. If laundry cleaning and drying services were already rendered on or for the host site before it is repurposed as an ACS, then a suitability and risk assessment should be conducted to ensure that the volumes of laundry generated and infection prevention and control measures are conducive and modifications made as necessary. A new full laundry service may take time and resources to establish, and in general, will not be established at a host site as a temporary solution. Where the site and circumstances advocate for the design of a new laundry or the upgrade of an existing laundry, the IUSS Laundry Services for Hospitals should be applied.
==== Siting and model selection considerations ====
When an existing laundry is being assessed for use or a new one is being planned the following considerations apply:
* Water and power capacity.
* Ease of access to the ACS’s main corridors and internal transport routes.
* The noise factor of the facility and its impact on nearby patient care departments.
For outsourced departments:
* Delivery areas to allow sufficient space to ensure that vehicles can manoeuvre and park easily at the reception and dispatch bays.
* Access to the ACS service roads and public roads.
==== Functional requirements ====
The most basic equipment needed in a laundry includes washing machines, tumble dryers and ironing machines. Equipment requiring steam is not recommended for a temporary facility. The sizing of the laundry, equipment and engineering services can be modified based on the principles provided in the IUSS Laundry and linen.
=== Catering services ===
Kitchenettes, that is, areas for tea, coffee and snacks, mainly for staff, in staff pause areas are discussed elsewhere in this document.
Catering services (for staff and patients) may be provided on- or off-site. If the ACS is to be established with easy access to a suitable, existing, functional kitchen service (e.g. hotel, military or hospital catering) which can meet the additional demand of the ACS, then this should be used. If there is no suitable facility, catering should be outsourced via a suitable off-site supplier. Only in the event that no feasible or suitable, existing facility or local supplier is available, should a new catering service be established at the ACS. Detailed guidance for the sizing, design and layout of catering services can be found in the IUSS Catering Services for Hospitals.
The kitchen (for on-site catering) or preparation area (for off-site catering) should be located with easy access to the point of delivery and storage of food. Adequate food and equipment storage space must be provided.
It is recommended that patient and staff meals, where provided, be supplied in disposable, containers, suitable for incineration, and that these are disposed of as risk waste immediately after use.
Where off-site catering is used, a suitable area for receiving should be provided. Space will be required for sorting meals for distribution and collecting and storing dirty dishes, washing dirty dishes, if necessary, and disposing of left-over food and disposable containers and utensils. The size of the areas required for this will depend on the number of meals delivered.

=== CSSD ===
The primary function of a Central Sterile Supply Department (CSSD) is to provide an efficient, economic, continuous and quality supply of disinfected and sterilised items, when needed, to all patient-care service points in the ACS, and to receive returned contaminated items for cleaning.
CSSD with limited sterilisation capacity (autoclave) but sufficient disinfection capacity (instrument washing). The layout requires a designated clean and dirty areas with a hard barrier between to avoid cross-over of staff and equipment. Work is unidirectional - flows from dirty – to clean - to sterile areas.
This yields three distinct zones:
1. Receiving and cleaning with pass-through windows
# Dirty receiving with Perspex or glass partitioning
# Dirty utility
# Decontamination and cleaning/wash area with throughput instrument washing
# Trolley wash/Park – external
2. Inspection, assembly and packaging with pass-through windows
# A tabletop autoclave
# Instrument washer
# Clean Packing area
3. Sterile processing, storage and distribution. (Separate issuing area from receiving area) with pass-through windows
# Store -linen and consumables
# Sterile pack store
# Issue - Collection hatch with Perspex or glass partitioning
Must also have a secure, separate receiving area for consumables receiving and storage.
An example of a CSSD unit is shown in Figure 21.T

[[File:An example of a small CSSD facility.png|600px|thumb|none|An example of a small CSSD facility<ref>IUSS 2014, https://www.iussonline.co.za/norms-standards/support-services/24-central-sterile-service-department</ref>]]

To be understood: Quality of services, eg. water (including a source of distilled or ionised water for rinsing of bronchoscopes) and electricity, quality of management, if equipment is appropriate for needs and fit for purpose, what is required of the equipment in the near and far future (relocation?), compliance with S.A. National Standards for CSSD, compatibility of equipment and devices, correct chemicals, maintenance of equipment, training of operators. Although the use of disposable breathing circuits and accessories (masks) should be encouraged, the capacity to disinfect these items if disposable is not available must be considered.

The CSSD must be sized to serve the ACS. Considerations are workload and space requirements. CFSA has extensive [https://www.fidssa.co.za/Content/Images/CFSA_SOP_2018.pdf standard operating procedures] for CSSD.

Workload: Number and type of procedures, number of procedure rooms, eg for bronchoscopy, operating hours, available inventory, volume of work and peak times, degree of mechanization, eg. manual or automated instrument washing, amount of product to be stored – chemicals, barrier wrap, chemical indicators, etc., storage and distribution records, quality records – eg. equipment checks, disposal needs.

Space requirements: Space for separation of clean and dirty, allow for unidirectional movement, allow space to manoeuvre trolleys (queue, pack/unload), reduce lifting and carrying heavy items, reduce awkward movements, allow for tidy work areas. Insufficient space will compromise sterility!

Preference should be given to construction materials and finishes which are suitable for frequent cleaning and tolerant to chemicals, including bleach (sodium hypochlorite). Impermeable flooring, non-slip and smooth washable walls are needed. Joints at walls and floors and coving at wall edge, and exposed drains should be avoided. Worktops should be sealed and should be ergonomically suitable.

Ceiling heights below 2.8m may be vulnerable to damage from humidity Where steam and moisture are generated. Noise – insulation of washer-disinfector and steriliser in technical walls will reduce noise. Lighting: Natural light if possible – windows sealed. High luminance if artificial lighting. Open, slatted shelves for sterile store area. Sinks for manual washing: At least two basins, deep (25cm at least) basins, 91 cm from floor, wide and long enough for the biggest instrument tray or container, water ports for flushing of lumens.

The CSSD space allocation and layout should be determine based on what procedures and which medical devices will be required. A typical [[equipment list is provided here]].

=== Maintenance and cleaning ===
Maintenance and cleaning services must be accommodated with offices located away from clinical areas.

=== Mortuary services ===
The National Department of Health has issued guidance on handling of dead bodies and infectious remains<ref>National Department of Health South Africa, 2020 [https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf]</ref>, which should be applied to ACS. While some guidelines have recommend that bodies of persons who have died from COVID-19 should only be held for a very brief period prior to cremation or treatment for burial<ref>Zhejiang University, 2020 [http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm]</ref>, the WHO holds the view (at the time of writing) that there is no evidence of persons becoming infected from exposure to bodies during normal ceremonial and burial activities. However, appropriate PPE should be used when handling such bodies with additional airborne precautions to be taken during autopsies<ref>WHO, 24 March 2020 [https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf]</ref>.

Either body cabinets or a refrigerated room could be used for body storage.
==== Location and layout of mortuary service ====
It is likely that not all alternative care sites will have a mortuary. Those without a mortuary must have a holding room that is located away from general access areas. This holding room must be suitably sized and conditioned. A recommended room size is 3.5 m x 3.4 m<ref>IUSS Adult Inpatient Services, 2014, [https://www.iussonline.co.za/docman/document/clinical-services/65-adult-inpatent-services-gazetted/file]</ref>
A mortuary should be located so that it is easily accessible to mortuary staff and related service providers and visitors without presenting either aesthetic, emotional or ethical problems for unrelated staff, patients or visitors. It should be separate from the general facility, allowing access for the family to view a body without passing through any potentially contaminated area of the facility. The visitors’ entrance should be external and completely separate from other access points.
Appropriate routes should be designated so that bodies are not moved through public-access areas.
==== Sizing of mortuary ====
The layout and size of a mortuary are largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.
==== Services ====
The following services are required in a mortuary:
* Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.
* Sluicing facilities are to be provided in both the body-preparation and autopsy areas if they are not a common area.
* Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush-fitted stainless steel grids.
* No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.
* The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.
* Anti-backflow devices should be fitted to the water-supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.
* Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.
==== Finishes ====
Wall and floor finishes should be impervious to liquids and easily cleanable.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Engineering and environmental controls''' ==

=== General indoor environment conditions ===

Existing environmental control systems should be modified to suit requirements in the facility. The following issues should be considered:
* Systems should be set to maximise the introduction of fresh air and maintain the pressure regime (see ventilation).
* The following internal temperature range should be maintained 19 - 24oC.
* Cooling systems should be able to cater for projected internal heat gains from people, lighting and equipment. Indicative heat gains in treatment areas are 8W/m2 from people, 15W/m2 from lighting and 3 W/m2 equipment and in critical care areas 16W/m2 from people, 15W/m2 from lighting and 60W/m2 equipment.
*As heat gain can vary widely between items of equipment, heat gain and utilisation rates for equipment should be obtained from the manufacturer to establish this more accurately.

=== Solid waste from ACS ===
According to the National Department of Health COVID-19 Environmental Health Guidelines
“All solid waste from the facility should be regarded as potentially infectious material and therefore appropriate precautions should be taken". The management of healthcare risk waste (HCRW) should follow the correct identification segregation, storage and disposal processes as indicated in SANS 10248-1.

* HCRW is segregated at the point of generation and shall be containerized to minimize the risk of contamination.
* Waste generated from patients in isolation or quarantine in a designated facility health facility is treated as health care risk waste (HCRW) as per SANS 10248-1-2008.
* The HCRW is properly packaged in a sealed, leak and puncture-proof containers/ boxes.
* The HCRW is labelled with the biohazard symbol/ sign and marked “Corona virus or COVID-19”.
* The HCRW is stored separately from other waste generated.
* The collection, transportation, treatment and disposal is provided by only an appointed/ appropriate contractor/ service provider, however, ensure that waste is safely stored until the health care waste management company can pick it up and that the company knows and acknowledges that waste was generated by suspected or confirmed COVID-19.
* The waste management company collecting must ensure that and treated and disposal is conducted at license waste treatment/ disposal facilities .
* All personnel or staff in contact with patients must be geared with appreciate personal protective equipment (PPE’s) at all times to prevent exposure or risk to health.
* Monitoring should be done at such facilities.
* All, bags, bins and boxes must be adequately sealed, as not to leak any fluids, and must be wiped down with 0.05% chlorine solution

Measures developed should consider the following.
* Develop a waste management plan following national guidelines and best practice standards for the disposal of medical waste (WHO, 2020).
* Establish procedures with medical waste service providers to regularly pick up the waste and dispose of this safely.
* Provision should be made for 5kg of solid waste per bed per day and this should be monitored and supplemented where it appears this may be inadequate.
* Ensure that access to waste is secure and controlled, for instance, by using lockable waste 1000l containers kept in a location that can only be accessed by health facility and nominated service delivery staff.
* Vermin control programs must be implemented throughout the site with HCRW collection points prioritised
* Provision for safe cleaning and disinfection of reusable containers should be provided. Cardboard, single-use HCRW boxes are removed from site and incinerated.
* Waste must not be allowed to accumulate or be stored inappropriate or unsecured containers.

== '''Engineering Services''' ==
Engineering services include patient services, ventilation, electrical power, water, medical gases, oxygen, compressed air, vacuum, lighting, and fire safety that support the needs of the patients and medical staff under normal and emergency situations. Good practice standards are provided in:
* IUSS Building Engineering Services<ref name = "IUSSBES">IUSS 2017, [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file]</ref>
* NHS Nightingale Instruction Manual<ref name="BDP2020">BDP 2020, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf]</ref>.
The guidance below draws on these and other manuals and standards. 

=== Building ventilation ===
==== Mechanical ventilation ====
While SARS-CoV-2 RNA has been detected in aerosol form, in experimental mechanical aerosolization studies, it is primarily spread through droplet and contact spread and the potential for airborne transmission is thought to be low.
However, the following advice is provided by ASHRAE regarding HVAC systems in general spaces (not specific to healthcare):
Effective high levels of ventilation must be achieved in the facility. Existing ventilation systems should be tailored to suit internal layouts and requirements and the following measures should be taken.
* Mechanical systems should be set to maximise fresh air supply to the facility. There should be no recirculated air without HEPA filtration or other validated decontamination processes.
* A pressure regime should be established, as shown in figure 2, to 'push' air from clean areas, to dirty areas and then out of the building.
* A clean air supply of over 10 L/s per person should be targeted for odour control.
* Fresh air supply shall not be located near patient beds to avoid drafts in winter.
* Extraction points can be located near patient beds in isolation wards or at a high level in long-stay wards. Short-circuiting of air between high-level supply and extraction is a performance risk in winter.
* Noise from ventilation systems and fans shall be below 45 dBA
* Protected lobbies, internal partitions, door arrangements, fans and extracts should be used to maintain the pressure regime and airflow as indicated in the diagram below.
 

[[File:Ventilation in temporary facilities.png|600px|thumb|none|Ventilation in temporary facilities<ref name="BDP2020"/>]]

==== Natural ventilation ====
The airflow direction between naturally ventilated zones may fluctuate according to the wind direction. This is not of concern within and between contaminated zones where occupants are either protected with mandatory PPE or confirmed to be infected with disease strains similar enough so as not be able to reinfect others. Where levels of occupant susceptibility to an airborne disease is significantly different, the less susceptible areas (such as PUI areas and uncontaminated areas) shall be protected from the naturally ventilated and contaminated areas by mechanical ventilation systems with a capacity sufficient to overcome the expected natural ventilation pressure fluctuations (typically 5-15Pa). Where such mechanical ventilation systems are not feasible or expected wind pressure is too great, zone adjacently must be avoided.

===Ultraviolet germicidal Irradiation===
The application of Ultraviolet Germicidal Irradiation (UVGI) for room air disinfection is well understood and is proven to be effective in the disinfection of microorganisms including M. tuberculosis (TB) in air. UVGI should, therefore, be considered as a valid element in indoor airborne infection control strategy for high volume settings. Studies have demonstrated the importance of good vertical air mixing in the room, and the safety of UVGI application. In areas where UVGI is indicated, the design and development of UVGI systems should be in accordance with the [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]<ref>van Reenen et al,2019 [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]</ref>

=== Electrical power ===
Sufficient and reliable power must be available at the facility for envisaged medical equipment, medical gases, lighting and building ventilation equipment. Power installations for the temporary facility can be divided into three zones as indicated below. These are existing services, the temporary service zone and services in each bay.
The following should be considered by competent engineering professionals.

=== Existing services ===
*Capacity: Evaluate whether sufficient power to accommodate envisaged medical equipment, additional lighting and heating, building ventilation and air conditioning can be provided. If existing capacity is insufficient, investigate if it is possible to route additional power from additional locations/transformers around the site or from adjacent sites.
* Safety: The existing electrical distribution network must be able to supply the required equipment load. If this is insufficient/appears unreliable, identify how this can be supported.
* Resilience: Evaluate back-up power and a UPS capacity against essential services demand. If existing capacity is not sufficient, source and establish temporary service capacity.

=== Temporary service zones ===
*Identify locations for temporary service zones where equipment can be located.
*Ensure that equipment and maintenance access is safe and easy.
*Ensure that all distribution boards, circuit breakers and cables are clearly labelled.
=== Services in each bay ===
*Provide pre-wired power strips/trunking as per bay requirements.
*Check that these include sufficient electrical outlets and service points for envisaged equipment.
*Ensure that trunking will carry required equipment loadings. The IUSS Building Engineering Services Guide can be used to check requirements<ref name = "IUSSBES"/>.

[[File:Layout_of_power_in_a_temporary_installation.png|600px|thumb|none|Layout of power in a temporary installation <ref name="BDP2020"/>]]
----

=== Water ===
Water points are needed for handwashing, showers and cleaning. The following issues need to be taken into account.
==== Supply ====
Onsite cold water storage, dedicated to the domestic water requirements of the facility, should be provided. A minimum usable volume of 500 litres per bed should be available.
Hot water storage and consumption should be confirmed by an engineer, as follows:
*Storage 25 L per bed.
*Consumption 180 L/bed.day W/O laundry; 250L /bed. day W laundry.

==== Handwashing ====
See infection control for clinical wash-hand basins
==== Showers ====
Showers for staff coming off shift should be available. Staff flow routes exiting contaminated treatment areas should pass through gowning and shower areas.
----

=== Medical gases, oxygen and vacuum (suction) ===
Medical gases, oxygen and vacuum services will be required in the facility. Mobile gas supply requires piping between supply and patient and clutter floor space. Preferably used fixed installations for patient rooms/cubicles, if possible.

System capacity and point of use pressures and consumption rates are to be ensured at all points. WHO provides technical guidance on [https://www.who.int/publications-detail/oxygen-sources-and-distribution-for-covid-19-treatment-centres oxygen sources and distribution]. 
[[File:Medical gas service layout.png|6oopx|thumb|Medical gas service layout<ref name="BDP2020"/>]]
The following points should also be taken into account.
* For centrally supplied medical gas and vacuum services, system resilience and availability must be ensured.
* Compressors, tanks, accumulators, VIEs, headers and controllers must be secured from uncontrolled access.
* Where possible, gas piping should be reticulated below floors or in ceilings to ensure protection from tampering, damage and ease of access.
* Where reticulation is within open areas, high-level reticulation with point-of-use droppers is advised. Low-level reticulation within rooms is to be avoided.
* Flexible piping can be used, ensuring it does not present a contamination or fire risk and should comply with local regulations. Special care should be taken with flexible O2 piping, keeping it to a minimum.
* Vacuum piping may be contaminated, where point-of-use filtration and collection systems fail. Precautions should be taken when demounting or disconnecting temporary vacuum lines.
* Ensure that oxygen pipelines are designed to provide sufficient flow to all oxygen points in the facility. In terms of utilities, oxygen and medical air would be required. A temporary vacuum point can be provided by mobile medical vacuum units distributed throughout the unit.
* Mobile medical air supplies should be considered where reaching piped specifications are not feasible. Where flexible hoses are used for oxygen and medical air special precautions need to be taken. Flexible oxygen piping must be chemically safe for O2 use. Where perishable flexible piping is used for medical air, terminal filtration at the point-of-use may be required at point-of-use. Especially for long-term use.
* Electrical and gas services can be reticulated against pipe racks or boards fixed to the bed-heads for head to head bed arrangements.
* Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.
* Gas service outlets to be labelled and colour-coded with 3mm lettering.
* SANS 7396-1 should be used to specify the requirements from design to commissioning of medical gas and vacuum systems.
* Medical gas and vacuum pipelines shall be marked per SANS 7396-1 and ISO 5359, as applicable.
* Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.
* SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.
* Plain-ended copper tubing for low-pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.
* Laboratory gas taps and valves shall be marked as described in SANS 10140-4.

=== Lighting ===
Existing lighting systems may need to be modified to suit the clinical requirements in the facility. High bay lighting presents inadequate colour rendering quality for the accurate detection or easy diagnosis of certain clinical conditions. This needs to be evaluated in the selection of supplementary lighting systems.
*Lighting levels should be provided in line with the indoor lighting levels recommended in the Table 6 of IUSS Building Engineering Services .
*Mobile task lighting systems may be adopted in the serious and critical stay wards to supplement incorrect lighting quality.
*Emergency lighting and illuminated emergency egress signage should be linked to the back-up power system.
*External security lighting in external parking areas and spaces around the building should be enhanced to ensure the security of medical staff who need to change shifts at night.

=== Fire safety ===
A functional fire alarm system should be available to support the patient care setting. Fire is a very real threat due to the possibility of an oxygen-enriched atmosphere developing so ventilation is crucial.
The use of temporary facilities for medical care should note the following fire risks (NHS, 2020):
*Patients may have a very high dependency.
*Areas are not specifically designed for patients and do not meet guidance on fire compartmentation and progressive horizontal evacuation.
*Large numbers of patients supplied with oxygen up to 10 litres per minute.
*Possibility of oxygen concentrations exceeding those generally found in the atmosphere- less risk if effective ventilation or large volume i.e. high ceilings.
* Possibility of storage, in excess of 40 litres, of alcohol-based chemicals (such as hand-rub), necessitating a flammables cabinet on site.
*Staff who may not normally work together .
*Staff who may not be familiar with the area.
*Staff not trained in fire safety, progressive horizontal evacuation or oxygen isolation for the specific area.
These factors should be taken into account in fire risk assessments which should then address significant findings in an action plan. Fire assessments should be undertaken by a qualified person and shared with operations and building management staff within the facility. Measures developed should include:
*An automatic fire detection system
*An emergency egress plans are prepared that include patients who have a very high dependency.
*Signage, notices and lighting are installed and are working effectively.
*Management processes are in place to minimise the risk of fire from ignition sources, fuels and oxygen.
*Staff are trained and a fire safety guide sheet for staff is developed and issued.
*Emergency egress routes are kept clear.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Additional Resources''' ==
=== [[Directory of Service Providers|A Directory of Service Providers can be viewed here]] ===

=='''References'''==
<references />

[[Category:COVID-19| ]]
[[Category:Alternate Care Sites|Alternate Care Sites]]

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[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19|(Return to Top)]] 
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Infrastructure Guidance for COVID-19/Alternate Care Sites

2020-05-08T08:47:07Z

Peta: /* Environmental Controls */

[[Infrastructure Guidance for COVID-19|Return to Infrastructure Guidance for COVID-19]] 

== '''Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19'''==

This guidance work was initiated under the project titled: 
''Reducing Nosocomial and Community-Acquired Tuberculosis by Strengthening the Capacity of the South African Department of Health to Improve Implementation of Infection Control and Waste Management at All Levels of the Health System Under the President's Emergency Plan for AIDS Relief (PEPFAR)'' 

== '''Introduction''' ==
=== Purpose and approach ===
The global pandemic of COVID-19 caused by the coronavirus, SARS-CoV-2 is likely to result in a surge in need for medical care for Severe Acute Respiratory Syndrome (SARS) in South Africa. Considering the course of the pandemic in other countries, it is anticipated that South African hospitals will not have sufficient capacity to cope with the surge of persons requiring medical attention and that surge capacity via alternate care sites (ACS) will need to be established.
Surge capacity, contemplated here is not the frequent emergency department overcrowding experienced by healthcare facilities (e.g. Friday/Saturday night emergencies) or local casualty emergency that might overcrowd nearby facilities and have little to no impact on the overall healthcare delivery system. It is when a catastrophic event occurs and the affected population seek medical care from existing local healthcare facilities, causing healthcare infrastructure to become exhausted due to excess in demand. During a healthcare surge, the standard of care will shift from focusing on patient-based outcomes to population-based outcomes, and providers should anticipate “a shift to providing care and allocating scarce equipment, supplies and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals.”<ref>[https://asprtracie.hhs.gov/technical-resources/resource/491/altered-standards-of-care-in-mass-casualty-events Health Systems Research Inc., 2005]</ref> 

Surge capacity can be temporarily established in non-traditional environments, such as hotels, exhibition halls, community halls, and as field hospitals, on open spaces. 

In the context of this document, a quarantine site is a facility for patients who do not require continuous professional medical care, while an ACS is defined as a temporary facility that can provide continuous medical care for SARS. This document provides principles and considerations, high-level guidance for minimum requirements and examples for ACS. 

While an extensive set of health facility guidelines does exist<ref>[https://www.iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-servi IUSS Building Engineering Services (2017)]</ref>, these are applicable for conventional facilities and thus include services and guidelines that are not necessarily relevant to the treatment of a novel, highly infectious pathogen, with pandemic effects. Moreover, these do not provide well for the rapid and temporary establishment of facilities. 

In order to formulate high-level guidance, [[as invited by Business for South Africa]], the team reached out to professional industry bodies for inputs, in particular the South African Institute for Architects (SAIA), The Gauteng Institute for Architects (GiFA) [https://www.gifa.org.za/ Gauteng Institute for Architecture] and the [http://www.safhe.co.za/ South African Federation of Hospital Engineering (SAFHE)], by inviting input via a 36-hour research charrette. Relevant historical and contemporary literature was consulted, precedents identified and critically reviewed. An interaction with the team at Wuhan responsible for makeshift hospitals and emergency infectious diseases hospitals, Central-South Architectural Design Institute, was arranged with assistance of the Chinese Embassy. Material from the [[Infrastructure Unit System Support|Infrastructure Unit System Support (IUSS)]], international literature and guidance and input gathered from the broader architectural, engineering and healthcare professional communities was synthesised and moderated by the CSIR team. The draft was reviewed by an expert review panel. 
=== Acknowledgement of contribution ===
The contributions to the initial version of this were gratefully received. [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Acknowledgements|A list of these contributors can be viewed here.]]. 
New contributions are eagerly encouraged along with debate and discussion on the [[Talk:Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites|'''discussion forum.''']] tab above.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Scope and Assumptions''' ==
ACSs as discussed in this document are dedicated, temporary facilities for triage, testing, diagnosis, further referral and treatment of persons:
*suspected of having contracted SARS-CoV-2, (persons under investigation (PUIs)), who are symptomatic and/or are awaiting results,
*or are confirmed to be infected.
ACS will accommodate a variety of clinical, logistical, support and auxiliary services associated with the render of care. ACS will currently not be licensed to provide healthcare services. Since the ACS will operate in a non-healthcare facility, it cannot fully replace a hospital setting and its prime objective is to manage the patient load until the local healthcare system can meet demands. 

=== Exclusions ===
Quarantine facilities are accommodation facilities where a member of the community can remain for the duration of their isolation period. This is typically temporary housing for a cohort of people who do not need intensive medical attention but who cannot stay at home. Patients can take care of themselves and need limited monitoring by medical staff. Quarantine: Containing presumptive-case patients from each other and the general population.
Quarantine facilities – that is for asymptomatic persons who are in the community in self- or imposed isolation, but not displaying symptoms, or who are symptomatic, but are able to safely recover without clinical intervention and do not need continuous medical observation are not considered in this document.

=== Service regime ===
The following assumptions are made with respect to services under consideration.
* Temporary - limited to the part of the pandemic when the “conventional” hospital platform cannot meet demand. To be dismantled, thereafter.
* Uncomplicated, dedicated COVID-19 care is to be prioritised for ACS.
* Patients with comorbidities, paediatrics will be prioritised for conventional facilities, and only accommodated in ACS as a matter of last resort.
* 24 hour, 7 days a week operations. 

=== Assumed mechanism of transmission ===
Transmission of SARS-CoV-2 is understood to be from person to person firstly by [https://en.wikipedia.org/wiki/Transmission_(medicine)#Droplet_infection droplet] transmission, then by the [https://en.wikipedia.org/wiki/Transmission_(medicine)#Direct_contact contact] route and finally via airborne [https://en.wikipedia.org/wiki/Transmission_(medicine)#Airborne_airborne transmission] during or following mechanical aerosolisation. Water transmission risks are minor, occurring in special [https://en.wikipedia.org/wiki/Transmission_(medicine)#Fecal%E2%80%93oral Fecal-oral] circumstances. Reclassification of transmission mechanisms may nullify some of the approaches presented in this guidance. 

=== A call for strategic coordination ===
This document focusses on infrastructure requirements. These provisions are meaningless without staffing, equipping and resourcing. Whilst staffing, equipping and resourcing are not the focus of this document, these are likely to emerge as key constraining features. Resource constraints are likely to become acute during this pandemic. Doctors and nurses are already in critical short supply in South Africa and internationally, and are themselves susceptible to COVID-19 infection. Equipment and consumables are in short supply with heightened global demand, reduced manufacturing capacity and limits in trade flows. This necessitates strategic coordination, proactive planning, options appraisal and prioritisation. 

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Status Quo''' ==
=== Rationale and transmission status ===
According to the [https://en.wikipedia.org/wiki/World_Health_Organization World Health Organisation] (WHO), based on the largest cohort of COVID-19 patients, about 40% of patients with COVID-19 may have mild disease, where treatment is mostly symptomatic and does not require inpatient care. About 40% of patients have moderate disease that may require inpatient care; 15% of patients will have severe disease that requires oxygen therapy or other inpatient interventions, and about 5% have critical disease that requires the patient to receive mechanical ventilation. However, the evolution of the outbreak in some countries has shown a higher proportion of severe and critical cases and the need to rapidly increase surge capacity to prevent rapid exhaustion of biomedical supplies and staff. In some countries, doubling rates of cases every three days has been observed<ref>WHO-2019-nCoV-HCF_operations-2020, [https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf]</ref> 

South Africa has a high burden of disease, with a high prevalence of [https://en.wikipedia.org/wiki/HIV/AIDS_in_South_Africa HIV and TB]. Although evidence is yet to emerge of the effect of SARS-CoV-2 on a population with these pre-existing conditions, there is reason to proceed with caution<ref>The Conversation 2020, https://theconversation.com/tb-hiv-and-COVID-19-urgent-questions-as-three-epidemics-collide-134554</ref>. There is a potential direct and indirect benefit of ACS to people living with HIV and TB, as well as to general public health and the health system preservation. 

With the travel lockdown in place, and continued transmission, it appears that South Africa is on the cusp between cluster transmission and community transmission according to WHO’s classification, shown in the [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites#Key_clinical_and_infection_control_activities_for_different_transmission_scenarios_.5B3.5D|table below]], indicating that preparation should include temporary hospital facilities and mass critical care.

==== Key clinical and infection control activities for different transmission scenarios <ref>WHO 2020, [https://apps.who.int/iris/handle/10665/331492 https://apps.who.int/iris/handle/10665/331492]</ref> ====
{| class="wikitable"
|-
! !! '''No Case''' !! '''Sporadic Case''' !! '''Clusters of Cases''' !! '''Community Transmission'''
|-
| Faculty Space, Including for Transmission|| Usual Space. Enhanced Screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards). || More patient care areas re-purposed for COVID-19 within the health system, especially for severe cases || Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Staff|| Usual space. Enhanced screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards)||More patient care areas repurposed for COVID-19 within the health system, especially for severe cases||Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Supplies||
*On-hand supplies. Equip wards for COVID-19 treatment.
*Identify essential equipment and supplies, including oxygen.
*Prepare expanded local supply chain
||
*Expanded inventory of supplies with detailed protocols for use.
*Activate expanded local supply chain.
*Prepare national supply chain.
||
*Conservation, adaptation, selected re-use when safe.
*Activate contingency planning and procurement for essential equipment and supplies.
*National supply chain.
*Prepare expanded supply chain at the global level
||
*Activate contingency planning should critical equipment be in short supply.
*Determine allocation of lifesaving resources for HCWs and patients.
*Activate expanded global supply chain
|-
| Standard of Care|| Usual care with enhanced awareness and recognition of immediate needs for first COVID-19 patients|| Usual care and treatment for all patients, including those with COVID-19||Identify context-relevant core services. Shift service delivery platforms. Consider reduction in elective patient encounters, including elective surgical procedures.|| Mass critical care (e.g. open ICU for cohorted patients).
|-
| Care areas expansion|| No requirements for expansion|| Designate 10 beds per suspected COVID-19 case|| Expand COVID-19 patient care areas by a factor of 35 ||Expand COVID-19 patient care areas by a factor of 58
|}

=== Quantification of need ===
At this time there are various parallel initiatives aimed at forecasting the South African epidemic, quantifying the projected need for facilities, and a shortfall in existing capacity. At this time, there is no consensus on this. This section will be updated as further data becomes available.
ACS will prioritise mild to moderately affected COVID-19 patients where basic, targeted medical care will be provided. Should patients’ needs evolve, requiring escalation of care, then the transfer of patients from ACS sites to conventional sites of care will be needed as a matter of course, bringing with it logistical challenges and risks. In the event that the conventional hospital platform is unable to cope, ACS will have pressure to provide care for severe and critical patients, and finally for patients with comorbidity and special requirements, such as paediatrics, persons living with HIV (PLHIV), TB patients and pregnant women. The following pragmatic approach, aligned with the WHO recommended strategic approach, is suggested.
*ACS should preferably be identified with space for expansion.
*The set-up should be done so that levels of care can be upgraded to higher levels of uncomplicated care.
*A secondary upgrade for more diverse package of care may become necessary.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Strategic Approach''' ==
According to WHO, clinical interventions must be put into place immediately and then scaled up according to the epidemiologic profile.
[[File:COVID-19 Resource allocation.png|none|thumb|600px|right|WHO Strategic approach to clinical care]] 
Under this declared state of disaster, the clinical care strategy which cannot be accommodated within existing facilities, can, on a temporary basis be hosted in ACS:
*Within and around existing healthcare facilities, via reconfiguration and/or augmentation.
*In existing non-healthcare buildings suitable for repurposing, such as universities, hotels and conference centres, warehouses, gyms, hostels etc.
*On open fields, including paved parking areas with rapidly constructed, dismountable structures, such as modular tented structures or using rapid modular construction techniques. 

ACS will provide isolation, general (non-acute) care for patients with mild to moderate symptoms and as required, acute care for patients with severe symptoms. Containing confirmed-case patients from general population. Confirmed-case patients can be housed together en masse, while presumptive-case patients must be individually quarantined.
As shown in the WHO Strategic approach to clinical care, the WHO recommends a range of services to meet patient need (''Citation needed''). General (non-acute) care ACS model is designed for minimal acuity patients requiring minimal activities of daily living support (e.g. COVID-positive with minimal symptoms or require <2L of oxygen). Acute care ACS model is designed for higher acuity patients requiring closer monitoring or respiratory support (e.g. COVID-positive with pneumonia or respiratory distress requiring ventilator support). Paediatric patients are to be accommodated in separate wards, where strictly controlled visitation may be allowed. 
As a preliminary estimate, the following ratios of service is proposed:
[[File:COVID Ratios of Service.png|none|thumb|600px|center|COVID Ratios of Service]]

{| class="wikitable"
|-
! '''Case severity, risk factors<ref group="Notes"> Test suspect COVID-19 cases according to diagnostic strategy</ref><ref group="Note"> Known risk factors for severe COVID-19: age over 60 years, hypertension, diabetes, cardiovascular disease, chronic respiratory disease, immunocompromising conditions.</ref>''' !! '''Recommendations'''
|-
|Mild || Patient should be instructed to self-isolate and contact COVID-19 information line for advice on testing
and referral.
|-
|Moderate, with no risk factors ||Test suspected COVID-19 cases according to diagnostic strategy. Isolation/ cohorting in:
* Health facilities, if resources allow;
* Community facilities (e.g. stadiums, gymnasiums, hotels) with access to rapid health advice
(i.e. adjacent COVID-19 designated health post/EMT-type 1, telemedicine)
*Self-isolation at home according to National guidance
|-
| Moderate, with risk factors || Patient should be instructed to self-isolate and call COVID-19 hotline for emergency referral as soon as possible
|-
|Severe || Hospitalization for isolation (or cohorting) and inpatient treatment.
|-
|Critical|| Hospitalization for isolation (or cohorting) and inpatient treatment.
|}

=== Notes and References: ===

<references group = "Note" />
<references />

=== Typology dictates & case studies ===

[[File:NHS Nightingale Hospital London.png|thumb|NHS Nightingale Hospital London <ref name="NHS Nightingale Hospital London">Coronavirus: Building NHS Nightingale Hospital London, 2020 [https://www.bbc.com/news/in-pictures-52092253 https://www.bbc.com/news]</ref>, ]]
To meet the requirements set out in this guidance, prospective “host” sites should be carefully evaluated. The type of “host” site selected will strongly influence or dictate the choice of ACS service model.

No site is likely to meet all requirements and recommendations set out in this document. Adaptations and compromises will be necessary. Services should be provided on site where it is pragmatic to do so, for example where similar services are provided. Outsourcing can also be practical/feasible for some services, such as laboratory services, catering and laundry, provided suitable logistical arrangements can be made.

Some typological responses and service models are set out in precedent examples, shown below. The examples demonstrate that a variety of host settings are workable, provided that the appropriate utility can be contrived.

=== Pragmatic approach ===
Other than in metropolitan areas, co-location of ACS on the premises of, or adjacent to existing healthcare facilities will often be preferable because this is where intensivists and specialist clinical staffing will be available, and support services may be well established. Nevertheless, augmenting capacity at existing facilities should take into account current workloads and capacity to ensure that the COVID-19 surge disrupts normal service provision as little as possible, including continuity of care for patients with chronic conditions and TB and HIV patients. 

*'''[[Infrastructure Guidance for COVID-19/Alternate Care Sites/Case Studies|SARS ACS Precedents and Case Studies can be found here]] '''

=== Notes and References ===
<references />

== '''ACS Infrastructure Planning''' ==

=== Establishing a team ===
A planning team should be formalised to establish the minimum planning and operational requirements for the ACS and to liaise with the local community. The team should include individuals with expertise in the following areas (ideally with knowledge of healthcare delivery under emergency conditions):
*Disaster response / emergency management coordination,
*Clinical care and staffing,
*Infection Prevention and Control practitioners must be involved in all stages of planning, commissioning, in-use, and decommissioning of the facility
*Facility set-up, operations and management,
*Security,
*Transport (patient, staff),
*Engineering and project management,
*Procurement and coordination of supplies, equipment and pharmaceuticals, and
*Community liaison to ensure that concerns of the adjacent population on understood an addressed.
It is important to ensure compliance with health, safety and building regulations, by ensuring the involvement of relevant local authorities. Stakeholder engagement should be formally documented. Concerns and grievances should be systematically addressed.

=== Structural integrity and operational responsibility ===

'''Structural modifications:''' ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered. 

'''Competent person:''' All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed. 

'''Asset responsibility:''' Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented. 

'''Integrity and responsibility'''

'''Structural modifications''': ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered.

'''Competent person''': All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed.

'''Asset responsibility''': Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented.

'''Decommissioning''': Decommissioning of the facility shall be assigned to the competent person discussed above. All residual structures upon decommissioning shall comply with the National Building Regulations. Upon decommissioning, removal of equipment shall be the responsibility of the owner. An infection prevention and control practitioner should be engaged in the decommissioning phase to oversee terminal cleaning and disinfection of equipment and premises.

'''Closure''': Once all patients can be safely discharged or transported back to existing facilities for continued care and there are no ongoing healthcare surge capacity needs, the ACS can be closed. Shut down of an ACS will require decommissioning, identification of new homes or storage for equipment, and termination of ongoing contracts or arrangements. Shut down should be expedited so that the facility can quickly be returned to the control of the existing owners and returned to its usual function.

Action checklist items for ACS closure should include, but not be limited to, the following:
*conduct a site walk-through with the facility owner when shutdown activities are completed to ensure that terminal cleaning and disinfection of supplies and premises, removal of equipment and supplies, and other surge closure activities have been completed to the owner’s satisfaction.
*perform medical records storage procedures.

== '''Site Selection''' ==
When selecting a site, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital can be utilised to determine whether the site is suitable for a 100, 1000 or 2000 bed facility, as required. The following indicative minimum site sizes are needed:
*100 Bed ACS/ hospital conversion, requires ± 4 300 m2
*1000 Bed ACS/ hospital conversion, requires ± 17 600 m2
Evaluation should be done by examining plans (if available), satellite images, drone images, scans and by physical inspection (walkabout). A comprehensive photographic survey should be undertaken and retained for record purposes on the site inspection. This will serve as an audit record and may assist in returning the site to its original function on ACS decommissioning and closure. When scrutinising documents and conducting site inspections to confirm the suitability of a site to host an ACS, the following criteria should be taken into account.
=== Criteria ===
*Affordability (costs, including operational costs known and budget identified),
*Sufficient physical space and capacity to house the immediate need, with the potential to accommodate physical space requirements. For example, open site should not be sloping,
*Legal rights and encumbrances, including renewal opportunity,
*Good access to highway and main roads,
*Well secured perimeter and limited controlled access points,
*Proximity to other hospitals and care sites,
*Accessibility for key staff and public transport,
*Good vehicular access around the site to set up temporary equipment such as back-up generators,
*Free from clear and present danger,
*Outside attenuation zones, floodplains,
*Outside high wind zones,
*Structure in good repair,
*Effective onsite facilities management team who understand how systems work,
*Potential for expansion, if required,
*Access to sufficient capacity for
**potable water,
**adequate sewage,
**telephone,
**internet access with sufficient bandwidth,
**electricity,
*A zone for cleaning, disinfection, and decontamination of equipment at least 15 metres away from occupied areas with access to water, a hard impervious surface and drying areas in the sun, with runoff discharge into the sewer and not into marine ecosystems or the environment. Include area for cleaning and storage of cleaning equipment.
*Likelihood of acceptance of hosting an ACS by the adjacent and local community

=== Desirable ===
*Durable, cleanable surfaces,
*Large open spaces that can be converted to accommodate temporary structures,
*Good ventilation,
*On-site kitchen and laundry,
*Housekeeping staff (chemical and equipment storage, lockers, rest facility, administration office),
*Space conducive for staff respite area and locker rooms,
*Amenities with universal access,
*Fire protection safety and equipment,
*Elevator access for patients if the building has more than one floor,
*Capacity for expansion, and
*Accessible to at least two roadways to provide continued access in the event that one roadway becomes blocked on inaccessible.

== '''Infection Prevention and Control''' ==
General guidance for COVID-19 [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|Infection Prevention and Control]] can be accessed [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|here]] 

Infection prevention and control in the context of COVID-19 should respond to transmission routes of primary concern for the pathogen of interest (droplet and contact transmission, and management of risk waste) as well as infection risk of a general nature (water and sewerage, airborne transmission – under high TB/HIV burden, and general waste).
In addition to satisfying [https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html standard precautions for all patient care], transmission-based precautions should focus on three pillars: exposure reduction by spatial configuration, operational strategies, and personal protection.
=== Transmission-based precautions ===
'''Droplet and contact spread''': Transmission of SARS-CoV-2 virus occurs via droplet and contact spread. The virus has been shown to persist on surfaces for extended periods of time and is known to be efficient at infecting people. 

'''Medical waste and linen:''' As SARS-CoV-02 is carried in body fluids and faecal matter, disposal of contaminated items (tissues) and cleaning regimes (spaces, garments, linen) should be accommodated carefully in the workflow design and infrastructure provision. A site-specific waste management plan should be formulated in accordance with a site-specific waste management plan with reference to SANS 10248. 

'''Airborne transmission:''' Under exceptional circumstances, the risk of airborne transmission arises for SARS-CoV-2, as detailed below.
{| class="wikitable"
|-
!Airborne Transmission Risk Factors
|-
|
As SARS-CoV-2 is not considered airborne, respiratory protection against airborne transmission is not considered necessary, except where aerosolisation of particles may be a risk.
According to the CDC
*tracheal intubation,
*non-invasive ventilation,
*tracheotomy,
*cardiopulmonary resuscitation, or
*manual ventilation before intubation and bronchoscopy.
According to doctors in the field also when performing
*COVID-19 diagnostic sampling as patients can be induced to cough and sneeze.
*Suspected or confirmed comorbidity of TB is not an additional risk where correct COVID-19 PPE is applied.

|}
South Africa has a high prevalence of TB and HIV, and therefore, although the risk of COVID-19 transmission via the airborne route is not paramount, there is a high likelihood that undiagnosed TB infectious patients may present at the ACS for treatment. TB triage may be challenging in the ACS as there are symptoms in common (coughing) with COVID-19. This country-specific risk is taken into account in this guidance

=== Additional precautions ===
'''Water and sewerage contamination:''' The International Water Association [[Infrastructure Guidance for COVID-19/Alternate Care Sites/COVID-19 A Water Professionals Perspective|concluded]] that water and sewerage contamination is not considered to be a key risk factor for COVID-19. The panel expressed concern for “how waste and specifically wastewater (medical) would be handled by places (e.g., hostels, hotels) that are used to serve as interim COVID-19 quarantine or testing facilities or accommodation ([ACS]. These are places other than hospitals that are used in the interim for such purposes and do not usually handle wastewater from medical settings. Such facilities should be monitored carefully.” 

== '''Spatial strategies for infection prevention and control''' ==

=== Restricted access and zone control ===
The site will be arranged to establish clear zoning, with a clear restricted zone protocol and access protection. Zones should be deemed to be "contaminated" or "uncontaminated" with clear transition areas between them.

; Contaminated zones
: (also known as "dirty areas") are areas occupied by COVID-19 infected persons, PUIs, equipment, materials and supplies which have come into contact with such persons without yet undergoing a decontamination procedure. These areas will include patient ward areas and ablutions, patient admissions (including ambulance drop-off) and the associated clinical areas. Staff rest and dining facilities should be outside the contaminated zone. Limited stock for immediate use should be kept in the contaminated zone. Layout designs should consolidate contaminated zones as far as reasonable, and avoid uncontaminated zones as islands in contaminated zones.

; Uncontaminated zones
: (also known as "clean areas") are areas not generally occupied by PUIs or confirmed COVID-19 infected persons. Equipment, materials and supplies in these areas have not yet come into contact with contaminated zones or have undergone a decontamination procedure. These will include clinical management planning rooms, stock rooms, bulk stores, pharmacy, laboratory areas, kitchen and laundry.

; Transition zones
: (also known as intermediate zone) are the spaces through which transfer of people and goods from uncontaminated to decontaminated zones, and vice versa, occur. Materials from the contaminated zone should be decontaminated or contained in the transition zone. The transfer of goods and persons should be highly ritualised and, as far as possible, traffic across transition zones should be minimised. Transition areas should be strategically located to serve this function. Separation of in-going and out-going transfer of goods and persons is preferable. Transition areas include ambulance, trolley decontamination, CSSD, laundry and waste bagging areas, patient locker area and staff change areas with spaces for donning and doffing of PPE.

=== Site layout and master-planning ===
Spatial configuration and layout can ensure unnecessary cross-over of function is avoided. This entails the systematic separation of functions and the managed transition between activities to facilitate consistency of care, an orderly, efficient work environment, less waste and reduced risk for improved outcomes. To achieve this, functional relationships should first be considered at the site level before being considered at the building level. 

<gallery mode=packed heights=300px style="text-align:left">
Layout for a SARS facility, clustering functions with minimised cross-over.png|center|thumb|Layout for a SARS facility, clustering functions with minimised cross-over <ref name="Layout1">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Layout_for_a_Patient_cohorting_strategy.png|center|thumb|Layout for a Patient cohorting strategy <ref name="Layout3">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Tygerberg Hospital virus triage unit site layout.png|center|thumb|Tygerberg Hospital virus triage unit site layout <ref name="Western Cape Provincial Government, 2020a">Western Cape Provincial Government, 2020 a</ref>
</gallery>

The WHO's Clustering Layout <ref name="Layout1"/> and Tygerberg Hospital virus triage unit<ref name="Western Cape Provincial Government, 2020a"/> show worked examples of building and site layouts, which are configured with these principles, respectively. '''Cohorting''' is defined as clustering patients with similar or compatible clinical needs together for risk reduction, acuity, efficiency and quality management, as illustrated in WHO's Cohorting Layout <ref name="Layout3"/>

=== Workflow ===
Within individual functional zones, the workflow activities can be arranged to proceed from clean procedures to contaminated procedures. In the example below, the staff arrival, PPE donning, doffing and patient flows are worked to have controlled interaction and minimised cross-over

<gallery mode=packed heights=400px >
ACS HCW Flow.png |ACS Health Care Worker Flow
COVID-19 Workflow in small unit.png |COVID-19 Workflow in Small Testing Unit <ref name="Western Cape Provincial Government, 2020b>Western Cape Provincial Government, 2020 b</ref>
COVID-19 Workflow in large unit.png |COVID-19 Workflow in Large Testing Unit <ref name="Western Cape Provincial Government, 2020b"/>
</gallery>

As far as possible, a single direction flow of clean to dirty is recommended for all processes: support services, supply and waste.
The Small ACS unit workflow diagram<ref name="Western Cape Provincial Government, 2020b"/> illustrates the recommended separation of access and exit, separate waiting seats, for persons who may be COVID-19 infected. Separate spaces are provided for donning and doffing PPE. Staff change areas are provided.

In the Large ACS unit workflow diagram <ref name="Western Cape Provincial Government, 2020b"/>, there is a clear separation between staff areas and patient areas. Waiting seats are set far apart to reduce transmission risk. Staff change rooms are provided near the point of entry to the facility for staff to change from street clothes into medical work clothes. To prevent work clothes worn inside the facility from contaminating street clothes, these are kept in separate lockers. A step-over barrier from dirty to clean sides of the change room is helpful to enforce a mind-set of avoiding cross-contamination. Bins for contaminated garments are to be provided in change rooms. Shower facilities are to be provided for staff.

== '''Operational Strategies''' ==
=== Cleaning, disinfection and decontamination ===
Surface and substrate specification, and detailing of all areas should, as far as possible, allow for frequent:
*Cleaning with detergent and water.
*Disinfection with 75% alcohol solution (metal surfaces).
*[https://en.wikipedia.org/wiki/Sodium_hypochlorite Sodium hypochlorite] (1,000 ppm)/ Household bleach.
*Disinfectants listed on the EPA List N<ref>The United States Environmental Protection Agency, [https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 List N: Disinfectants for Use Against SARS-CoV-2 (Last Visited 2020) ]</ref> (for non-critical environmental cleaning).
*High-intensity ultraviolet surface disinfection (UV-C).
*Decontamination and sterilisation of clinical equipment.

=== Goods and waste management ===
Remove any unnecessary furniture, equipment and paraphernalia from all patient care and clinical areas. Provide a clear, secure space for waste management. Any potentially infectious waste materials generated at the ACS should be considered and treated as medical waste (health care risk waste). The applicable legislation is:
*[https://www.gov.za/sites/default/files/gcis_document/201409/35405gen452.pdf The National and Provincial Health Care Risk Waste Management Regulations].
*[https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf National Department of Health COVID-19 Environmental Health Guidelines.]<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>
Waste disposal bins should be positioned near the exit inside each patient rooms or wards to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another patient in the same room.

=== Materials and finishes ===
Floor materials must be:
*Level,
*Free of dust and oil,
*Impervious and smooth,
*Slip-resistant in wet areas (e.g. patient ablutions).
Smooth, cement screed floors are acceptable. Where hosting facilities have carpeted areas, a risk assessment of factors such as durability, hygiene and decontamination needs to be conducted. In cases where the acceptance of carpeted flooring is contradicted (but other factors make it a compelling option), temporary floor finishes or covering can be investigated.

== '''Personal protection''' ==
=== Hand sanitation ===
Where wash-hand basins are not provided, clinical wash-hand basins should be installed, at the minimum rate of provision of one wash-hand basin per 5 beds. Clinical wash-hand basins (see figure below) have a variety of features not present in standard wash-hand basins, which are preferable for infection prevention and control. Where standard wash-hand basins are provided, an upgrade is not necessary. In all cases, there should be no surfaces and no clutter, equipment or supplies in the vicinity of wash-hand basins, including surgical gloves.
<gallery mode=packed heights=400px>
Clinical hand wash basin.png|Handwash Basin <ref>de Jager 2020</ref>
Portable Wash-hand Basin.png|Portable wash hand basins can be provided in ACS <ref name="BDPa">BDP 2020, NHS nightingale instruction manual, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf</ref>
</gallery>

Where wash-hand basins are not available, portable units can be used, as shown above<ref name="BDPa"/>. Mounted brackets for hand sanitisers are to be provided for every two beds, preferably mounted near the foot rather than the head of the bed and at all common touch points such as entry points at ablution facilities, linen room, sluice, storerooms, medicine rooms/cupboards, near refrigerators, telephones, light switches, at entry/exit doors, etc.

=== Personal protective equipment ===
Donning and doffing points for personal protective equipment, and convenient, safe disposal of consumables to be placed at critical key points when entering patient areas.
----

== '''General transmission mitigation''' ==
=== Water and sanitation ===
To comply with National Building Regulations; Hazardous Biological Agents Regulations and National Department of Health COVID-19 Environmental Health Guidelines<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>.

=== Droplet aerosolisation ===
When designating areas for procedures during which aerosolization and airborne transmission risk is high, the building ventilation must be carefully considered to take into account downstream risks. In particular, consider to where potentially contaminated air, arising from aerosol-generating procedures, is exhausted. In general, air exhausted directly to the outside is diluted and considered safe, unless there are openings to occupied spaces near the exhaust air outlet. 

In the event that potentially occupied spaces will receive partially diluted or undiluted contaminated air, or where this is indeterminate, the aerosolising activity should be designated to an alternate area. In the event that an alternative is not available, some treatment regime (air filtration or air disinfection) is necessary. 

In most naturally ventilated settings, the airflow direction between zones may fluctuate according to the wind direction. Such high-risk spaces should not be adjacent to spaces with high susceptibility rates, such as PUI areas and uncontaminated areas. Contaminated areas should not be directly adjacent to clean areas unless mechanically ventilated. 
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|Guidance on COVID-19 building ventilation design is provided here]].

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Health, Safety and Well-being''' ==
In addition to the infection prevention and control measures discussed above, the following should be provided for health, safety and well-being.
=== General provisions ===
*Minimised and controlled entry and exit points, with suitable control.
*Clearly identified accessible and marked routes for patients, staff, goods and waste.
*Clear designation of restricted zones.
=== Site level provisions ===
*Safe staff parking and arrival of staff via planned and public transport.
*Clearly demarcated parking for people with disabilities.
*Arrival and departure point for patients via public transport, passenger vehicles, and emergency service.
*Limited safe patient parking.
*Supply of goods and removal of waste.

=== Within and between buildings ===
*Entrances with a clear opening width (CoW) of at least 900mm.
*Routes with a minimum width of 2 000mm free of hazards, for example, rubbish bins.
*All clinical, patient and support areas to be accessible by trolley.
'''Ramps''' should be of stable construction, capable of sustaining a mass of 300kg. They should incorporate side lips and the surface should be slip-resistant. Gradients should be as gentle as the circumstances allow. (Recommended maximum 1:20). 
'''Small changes in floor levels''' are not desirable, but where these exist are to be clearly marked with reflective paint/ tape, and lit at night
Elevators between different floors, where patients need access (The recommended minimum lift size for patient trolley/stretcher movement is 1 400mm × 2 400mm, however, this may not be possible). 
'''Pathways''' to be lit at night, where used at night. 
'''Staircases''' must be well-lit at night with non-slip surfaces and secure balustrades. 
'''Doors''', Double doors and automated or push-operated doors to all clinical areas are to be preferred, where these are newly installed or able to be retrofitted. Door closers are to be disabled, where not necessary to reduce touch surfaces. Hand sanitisers to be provided at where high touch common surfaces occur (e.g. wall-mounted at doorways).

=== Signage ===
The appropriate level of information to facilitate legibility, orientation and wayfinding. Minimum standards, signage to be:
*Clearly visible, simple font, font size, contrasting colours, placed in the field of vision
*Washable
*Comprehensive safety signage - fire signage (exits, equipment etc.)
*Restricted areas clearly marked
*Identification signage - each patient space to be allocated a unique number and a whiteboard or perspex sheet for writing the patient’s name
Signs should be posted immediately outside of patient rooms indicating appropriate IPC precautions and required personal protective equipment (PPE).
Signage of a temporary nature can be provided on laminated white A4 sheets attached eye-level. The text should be black sans-serif (for instance Arial) text at least 40point size and centrally positioned on the sheet. Detailed guidance on signage is provided in IUSS Inclusive environments.
=== Safety and security ===
Upon identification of the ACS host site, a team should be convened to conduct a multidisciplinary safety and security analysis. These critical team members need to form the working committee responsible for undertaking the detailed assessment of the existing facility’s security. They should analyse data about the security system’s condition and review existing security concerns or issues that are reasonably likely to become concerns in the near future. The figure below represents a five-zone approach to security, which is a recommended, systematic approach to security.
[[File:Zonal approach to security.png|center|600px|thumb|IUSS Security- Zonal Approach to Security <ref name="IUSS Security">IUSS Hospital design principles - Security [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file]</ref>]]
The security strategy should take into account that whilst clinical services and some logistical and support services will be required 24 hours a day, seven days per week, some support services, logistics services and auxiliary services may only be operational for the minimum periods required to meet demand. These functional elements should be capable of being secured, for example over weekends and at night, as the case may be.
Detailed guidance is available in [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file IUSS Hospital design principles - Security] <ref name="IUSS Security"/>

=== Comfort and dignity ===
Supplemental heating: Patient health and comfort are dependent on, amongst others, maintaining body temperature. The ACS structural technology must be selected to achieve the general indoor environment conditions discussed in a subsequent section for all clinical and occupied areas. As we are moving into South African winter supplemental heating may be required, especially in the evenings, in order to avoid hypothermia. Use of fans, bar, radiator or gas heaters should be prohibited. Unless clinical areas can be maintained above 18 degrees centigrade, patients should each have an infrared heater available, in addition to blankets. Personal/ donated blankets can be considered if they are laundered first and could be destroyed upon discharge.
Mobile screens should be available to provide privacy where necessary (e.g. during consultations or procedures).
<gallery mode = packed heights = 400px>
Bed_Isolator_-Vietnam.png|thumb|Flexible Barrier Isolator<ref>WHO. (2020), Severe Acute Respiratory Infections Treatment Centre. Geneva, Switzerland : WHO- World Health Organization</ref>
ACS Cohort beds.png|ACS Cohort beds.png|thumb|Excel Centre London 04-2020 <ref>Architects' Journal 2020, [https://www.architectsjournal.co.uk/news/nhs-nightingale-bdp-on-the-first-nine-days-converting-the-excel-centre/10046749.article https://www.architectsjournal.co.uk/news]</ref>
</gallery>
Some solutions which address patient privacy and dignity are depicted above.

=== Notes ===
<references/>

== '''Schedule of Accommodation''' ==
Based on clinical needs of the ACS, a schedule of accommodation can be crafted capturing the clinical, clinical, logistical, support and auxiliary services associated with the render of care. When deriving a schedule of accommodation, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital tool can be used. Functions to be accommodated are: 
'''Clinical services''': Triage, rapid assessment of persons entering the facility, to expeditiously identify and render the appropriate service. Admissions and registration. Inpatient accommodation is to be organised according to cohorting principles, discussed above. Testing and diagnostics, including laboratories and x-ray. Safe storage and dispensing of drugs to patients.Offices for clinical administration and clinical planning meeting rooms in the clean zone are needed. 
'''Logistical services:''' Logistical services will entail management of flows of people, goods, services and information to and from the site, as well as within the site. It includes security and communication arrangements. Staff entry, preparations to transition from outside to clinical work environment, including pause areas for relief. Emergency services, visitors. Goods, supplies and storage and waste removal and/ or treatment.
Support services key to the provision of clinical services should be separated so that the risks associated with that particular activity can be managed. 
'''Support services are:'''
*Laboratory services
*Catering
*Laundry
*Environmental cleaning and housekeeping
*CSSD
*Maintenance and cleaning of surrounds, eg. waste areas
*Porters/”runners”, stretchers/wheelchairs
*Mortuary
* Security
Support services can be provided off-site, in which case, safe, secure and efficient transfer and logistical arrangements should be designed. 
'''Auxiliary services:''' Auxiliary services are services which may be provided on or near the ACS site, but which are not directly related to core clinical care. This included overnight accommodation for staff who may not wish to return home to avoid exposing their families, or who need rest between shifts, or for discharged patients awaiting transport home, volunteers who have recovered from SARS-CoV-2.
Limited psychosocial services and allied health services may also be provided on or near ACS for example by approved partners.
Examples of schedules of accommodation for patient and support spaces for a protective isolation ward is available [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedule for COVID-19 Isolation Wards|here]] and mild to severe cases [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedules for COVID-19 Wards for Mild to Severe Cases|here]].

== '''Clinical Services''' ==
=== Triage ===
Confirmed COVID-19 cases and PUIs who are referred from a testing facility or a higher level of care, will enter the facility in a triage area to receive vital screening and initial assessment. They will be registered and admitted to inpatient care. They will be assigned a "ward" or section of the facility - based on disease status and acuity. These are Protective Isolation, the Mild & Moderate ward, or the Critical & Severe wards. Patients should be clustered according to gender. As far as practicable, ablutions for each gender, isolation patients, paediatrics and staff shall be separately provided. Paediatrics patients, if admitted, are to be assigned a dedicated section.
As patients recover or deteriorate, they may be relocated to the appropriate section/ ward.
Once the patient has sufficiently recovered and a negative test result is received they will be appropriately decontaminated and discharged, collecting medication from the dispensary on exit. Patient movement between various sections of the ACS will be restricted as far as possible, with mobile radiology units, in-ward medication dispensing and in-ward food service.

=== Inpatient ACS accommodation ===
Separate spaces for:
*suspected, unconfirmed cases, under observation (PUIs), to be accommodated in isolation facilities (separate rooms, if possible);
*patients with confirmed COVID-19 with mild to moderate disease, not requiring dedicated oxygen therapy;
*patients who require dedicated oxygen therapy;
*patients requiring mechanical ventilation; and
*recovered/ confirmed negative.
==== Protective Isolation Facilities ====
Suspected, unconfirmed cases, under observation – persons under investigation (PUIs) to be accommodated in protective isolation facilities (separate positive-pressure rooms, if possible). PUI are restricted to their rooms. All food and laundry services will be brought to the PUI rooms to reduce interaction and potential contamination. All waste will be collected by facility staff and taken to waste handling areas. Infection prevention and control measures are put in place for the handling of used food utensil and laundry as well as waste collection. PUI areas will have restricted access, including for staff serving other inpatient sections, for confirmed cases.

==== Inpatients accommodation for confirmed COVID-19 ====

Inpatient facilities confirmed positive COVID-19 can be accommodated in large shared ‘wards’ with partitioning between patients. Partitioning between patients is optional. Partitioning is preferable to curtains found in conventional hospitals, as they are more conducive to daily cleaning. If curtains are used, antimicrobial treated fabrics with biocide used to treat the curtains has been tested to international standard EN 14476 and shown to be effective against H1N1 Influenza A Virus (Swine Flu), >99.999% kill rate in 5 minutes and measles morbillivirus, >99.99% kill rate in 5 minutes are preferred. If only separate rooms are available, patient monitoring and surveillance will need to be accommodated. This phase of treatment has a lower area/space requirement compared with PUIs, as cross-infection between patients is less of a concern. Shared ablution facilities are acceptable. It is recommended that, at least, two general accommodation ward areas be provided. 

a) Mild and moderate patients, and 
b) Serious and critical patients. 

The room must have openable windows for natural ventilation if a dedicated positive pressure ventilation system is not available. Ducted ventilation systems shall not be shared between PUI areas and confirmed COVID-19 patient areas. 
[[File:COVID-19 ACS - protective isolation – bed layout.png|thumb|center|800px|ACS - protective isolation – bed layout]]
[[File:COVID-19 ACS – mild-moderate patient bed layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient bed layout]]
[[File:COVID-19 ACS – mild-moderate patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient shared ward layout]]
[[File:COVID-19 ACS – severe-critical patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – severe-critical patient shared ward layout]]

Examples above show bed layout with bed spacing for protective isolation, a mild/moderate patient and a mild/moderate patient shared ward and for a severe/critical patient

=== Patient services ===
Patients in ACS will not generally be ambulatory and will be confined to their room, or cubicle in a bed. In general, domestic beds or hospitality industry (hotel) beds are not suitable for patient care. These should only be used where a hospital-grade bed cannot be sourced, as hospital beds are designed for ease of cleaning and decontamination (for infection prevention and control) and with patient and ergonomics, safety and comfort taken into account (they prevent back injury for nursing staff and can help to prevent bedsores). The higher the specification of bed, the more suitable it is for the higher levels of care. Lockers for patients personal belongings should be provided in the uncontaminated zone (in which case bedside lockers will not be necessary), and it is preferable (where bedside lockers are not provided) for overbed tables to be provided, per bed, if possible. 
The following beds are suitable:
*Repaired and refurbished beds from condemned hospital stocks.
*South African National Standard, SANS 521:2013 Edition 3.5, on Hospital beds and cots ISBN 978-0-626-28830-3.
*Beds listed on the National Treasury (See [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Hospital Bed Specification|specification]]).
The table below details the minimum services required at each patient bed. Details on these services are discussed in a subsequent section of the document.

{| class="wikitable"
|-
! Service/ Capacity!!Triage!!Isolation !!Mild – moderate inpatient!!Severe case wards!!Critical case wards
|-
| Power – 16A 230V Single socket outlet||As needed ||1 per bed||1 per bed||3 per bed||6 per bed
|-
| UPS Power – 16A 230V Single socket outlet ||As needed||1 per bed||1 per bed||1 per bed||2 per bed
|-
| Medical Air<ref group="Note">Mobile units recommended for intermittent use. 3 per 20 beds</ref><ref group="Note">There are some ventilators which have built-in compressors allowing them to function without Medical Air. This is however, not the norm. With Ventilators probably being the most difficult medical device to obtain at present, it would be prudent to rather allow for Medical Air at each bed.</ref> (LP)400kPa||No||Yes||No||Yes||Yes
|-
| Medical O2 -400kPa||Portable/shared||Portable/shared||No||One||Two
|-
| Vacuum-40kPa||No||Portable/shared||Portable/shared||Yes||Yes
|-
| Equipment rail||||||||Yes||Yes
|-
| Upper room UVGI||Optional||Optional||||||Optional
|-
| Examination light||No||No||Yes||Yes||Yes
|-
| Room Ventilation rate||60 L/s per person||10 L/s per person||10 L/s per person||10 L/s per person||12 ACH
|}
'''Notes: '''
<references group="Note" />

Two additional 16A 230V single socket outlets, one two-pin outlet and a worktop should be provided for every 32 beds (or part thereof), for:
*Electrocardiograph (ECG): Could be omitted if monitors have a full 12 lead ECG function.
*Blood gas analyser: Could be omitted if a Lab Services are available.
*Staff cellphone charging.

Example of healthcare technology to be provided for critical care patients is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]. Severe patients may be provided continuous positive airway pressure (CPAP). Emergency trolleys (“crash carts”) are to be provided in patient areas with convenient access to patient beds, out of the passage of corridors and is moved to the patient when needed. 1 crash cart for every 16 patients (or part thereof, with at least one dedicated for PUIs. An example of provisions for a crash cart is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]
==== Patient ablutions ====
[[SARS-CoV-2 is found in faecal matter]], so careful management of patient body fluids is crucial and convenient, practical support for frequent cleaning of ablutions especially shared ablutions is necessary. Dedicated ablutions (toilets and showers) are to be provided for patient use. Toilets and showers should be in separate rooms.
Hand washbasins and or/ hand sanitiser should be provided both inside and outside the toilet room so that patients can wash their hands on the way in and on the way out of the room.
*1 toilet for every 8 persons.
*1 shower for every 8 persons.
*1 disabled ablution for every 8 regular ablutions (or part thereof).
*1 disabled shower for every 8 persons (or part thereof).

Critical and severe patients may be sedated and have a reduced need to access ablutions, ablution facilities proximity and provision can take this factor into account. Showers and wash hand basins should have hot and cold running water. Where possible ablution facilities must have openable windows for natural ventilation, if not possible the bathroom extraction and room ventilation system must be reviewed before admitting patient '''(see [[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|ventilation]]).'''

Portable toilets and showers may be used, provided that suitable hand wash facilities are provided. These will need to be suitably located, preferably in decentralised clusters, so that patients can easily access them without needing to walk very far. Ablutions should be located and designed in such a way as to provide visual and acoustic privacy, dignity and avoid disturbance of other nearby patients when accessing, using or cleaning the ablutions. Separate ablutions are to be provided for PUIs and confirmed patients.

====Makeshift sluice areas ====
In conventional hospital settings, sluice rooms are provided for cleaning and sanitation of soiled equipment, such as bedpans. In a temporary setting, such as an ACS, the establishment of a temporary sluice room may not be practicable, and there may not be facilities for emptying buckets, rinsing equipment etc.. The following is suggested:
Allocate a toilet, hand wash basin, not in splash range and restrict access to it for draining buckets and install a macerator for disposal of disposable bedpans. Electrical, water and waste supply points required as per supplier specification.
==== Dedicated patient treatment areas ====
The following dedicated, private spaces per ward for clinical procedures are recommended:
*Counselling and consulting room (can be shared), as shown in the figure below
[[File:Consulting room example layout.png|400px|thumb|center|Consulting room example layout]]
*Minor procedures room, as per the example provided in the figure below 
[[File:Treatment-minor procedures room example layout.png|400px|thumb|center|Treatment / minor procedures room example layout]]

== '''Logistical Services''' ==
=== Communications ===
Electronic communication should be facilitated in all zones of the ACS by the provision of device charging stations, and wifi.
=== Visitors entry point ===
Visitors are strongly discouraged from entering the ACS.
*In paediatric wards, one parent may be accommodated to visit a patient. In such cases, direct access for the visitor should be provided so that the visitor does not need to pass through the general patient area. Appropriate PPE must be donned before entering the patient area and hand washing/sanitising must be done when exiting the area.
*Non-patients who are accompanying suspected patients to the facility for testing or admission must be accommodated in a well-ventilated, spacious waiting area. Signage in such waiting areas must inform visitors about symptoms, hand hygiene and PPE.
*Hand washing/sanitizing facilities should be provided.

=== Staff areas ===
==== Staff change rooms ====
A minimum of 9m² or 4m² for a single person, increasing by one m² for each additional person is required. The clean (street side) and dirty (contaminated facility side) of the change room should be separated by a step-over barrier.

==== Staff rest areas ====
Staff rest areas within the main facility should be provided with access to kitchenette facilities and staff ablutions.
=== Staff auxiliary services ===
'''Staff on-call:'''Since staff may be required to work long hours or could be required to be on-call, shared, overnight sleeping facilities can be provided for staff on duty, outside the contaminated area, but in close proximity on the patient areas. An example is set out in the diagram below.
[[File:Example of on-call sleeping area for staff.png|center|600px|thumb|Example of overnight sleeping area for staff]]

'''Staff accommodation:''' It is advisable to provide some staff accommodation for off-duty staff who may not have suitable alternatives, for example homes too far away, transport limitations or the requirement not to expose family members to risk. This should be provided in the vicinity of the ACS, but in a physically separated zone. This amenity can be outsourced.

== '''Support Services''' ==
=== Workflow principle ===
[[File:Linen processing cycle.png|none|thumb|Linen processing cycle <ref>IUSS 2014 [https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department]</ref>]]
Progressive workflow from “dirty” (that is contaminated) to “clean” linen is advisable to reduce the risk of exposure to contaminated materials. The workflow diagram below, showing the progression from the dirty linen receiving area, to the cleaning process, to decontamination and drying, and finally sorting and packing, and storage, illustrates this principle.
=== Laboratory ===
[[File:Example of modular laboratory.png|right|thumb|Example of modular laboratory]]
The WHO recommends the following laboratory diagnostic equipment be accommodated:<ref>WHO 2020, [https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items]</ref>.
<nowiki>• Lab screening test kit
• Lab confirmation test kit
• RT-PCR kit
• Extraction kit
• Cartridges for RT-PCR automatic systems
• Swab and Viral transport medium
</nowiki>
Additional accommodation requirements are:
# Reception counter- receiving specimens
# Testing with perspex/ glass screen
# Receiving/Data capture
# Specimen holding
# Toilet - staff
# Blood storage fridge
Can be provided as a modular laboratory unit as shown in the diagram.
=== Pharmacy ===
The purpose of the pharmacy is to provide medicines needed for inpatient treatment and care.
All medical supplies should be stored in a secure, climate-controlled area in close proximity to the patient treatment area. The pharmacy must have dry, lockable, climate-controlled storage of medications. Most pharmaceuticals are labelled with storage temperatures. The pharmacy should have adequate ventilation through an openable window to prevent humidity from building up in the room. Air-conditioning or mechanical ventilation can be provided, if necessary.

Dispensing areas must be well lit. Worktop in space for stock records and administration. Dispensing counters to have perspex or glass screens to serveries. Social distancing implemented at counter, between pharmacists/assistants and between chairs in waiting area.

Can be provided in a mobile unit.

=== Radiology ===
The purpose of radiology services is to provide chest X-Ray services for COVID-19 diagnostics. In general, CT scans, bucky rooms etc. associated with some radiology equipment require specialised infrastructure and therefore is not suitable for ACS. Radiology services can be provided as a mobile floor standing unit, or containerised unit. Alternative technologies such as Lodox and hand-held ultrasound devices are being investigated as potential options and could be confirmed as suitable for use in due course.
=== Laundry services ===
All dirty linen should be handled for bagging or binning inside the patient room/cohort area. The clean linen stock should be stored conveniently close to clinical areas, in a dedicated clean area in the uncontaminated zone. Used linen should be stored in a designated, safe, lockable holding area while awaiting collection. Interim storage areas for soiled linen at the wards is allowable; this may be in dirty linen/ utility room.
Any clean linen for PUI areas should be handled in spaces physically separate from dirty linen of confirmed patient areas. It may be necessary to completely separate PUI and confirmed patient linen streams. Soiled linen and clean linen bags and bins should be dedicated and not mixed.
Full laundry cleaning and drying services may be provided on-site or outsourced. If laundry cleaning and drying services were already rendered on or for the host site before it is repurposed as an ACS, then a suitability and risk assessment should be conducted to ensure that the volumes of laundry generated and infection prevention and control measures are conducive and modifications made as necessary. A new full laundry service may take time and resources to establish, and in general, will not be established at a host site as a temporary solution. Where the site and circumstances advocate for the design of a new laundry or the upgrade of an existing laundry, the IUSS Laundry Services for Hospitals should be applied.
==== Siting and model selection considerations ====
When an existing laundry is being assessed for use or a new one is being planned the following considerations apply:
* Water and power capacity.
* Ease of access to the ACS’s main corridors and internal transport routes.
* The noise factor of the facility and its impact on nearby patient care departments.
For outsourced departments:
* Delivery areas to allow sufficient space to ensure that vehicles can manoeuvre and park easily at the reception and dispatch bays.
* Access to the ACS service roads and public roads.
==== Functional requirements ====
The most basic equipment needed in a laundry includes washing machines, tumble dryers and ironing machines. Equipment requiring steam is not recommended for a temporary facility. The sizing of the laundry, equipment and engineering services can be modified based on the principles provided in the IUSS Laundry and linen.
=== Catering services ===
Kitchenettes, that is, areas for tea, coffee and snacks, mainly for staff, in staff pause areas are discussed elsewhere in this document.
Catering services (for staff and patients) may be provided on- or off-site. If the ACS is to be established with easy access to a suitable, existing, functional kitchen service (e.g. hotel, military or hospital catering) which can meet the additional demand of the ACS, then this should be used. If there is no suitable facility, catering should be outsourced via a suitable off-site supplier. Only in the event that no feasible or suitable, existing facility or local supplier is available, should a new catering service be established at the ACS. Detailed guidance for the sizing, design and layout of catering services can be found in the IUSS Catering Services for Hospitals.
The kitchen (for on-site catering) or preparation area (for off-site catering) should be located with easy access to the point of delivery and storage of food. Adequate food and equipment storage space must be provided.
It is recommended that patient and staff meals, where provided, be supplied in disposable, containers, suitable for incineration, and that these are disposed of as risk waste immediately after use.
Where off-site catering is used, a suitable area for receiving should be provided. Space will be required for sorting meals for distribution and collecting and storing dirty dishes, washing dirty dishes, if necessary, and disposing of left-over food and disposable containers and utensils. The size of the areas required for this will depend on the number of meals delivered.

=== CSSD ===
The primary function of a Central Sterile Supply Department (CSSD) is to provide an efficient, economic, continuous and quality supply of disinfected and sterilised items, when needed, to all patient-care service points in the ACS, and to receive returned contaminated items for cleaning.
CSSD with limited sterilisation capacity (autoclave) but sufficient disinfection capacity (instrument washing). The layout requires a designated clean and dirty areas with a hard barrier between to avoid cross-over of staff and equipment. Work is unidirectional - flows from dirty – to clean - to sterile areas.
This yields three distinct zones:
1. Receiving and cleaning with pass-through windows
# Dirty receiving with Perspex or glass partitioning
# Dirty utility
# Decontamination and cleaning/wash area with throughput instrument washing
# Trolley wash/Park – external
2. Inspection, assembly and packaging with pass-through windows
# A tabletop autoclave
# Instrument washer
# Clean Packing area
3. Sterile processing, storage and distribution. (Separate issuing area from receiving area) with pass-through windows
# Store -linen and consumables
# Sterile pack store
# Issue - Collection hatch with Perspex or glass partitioning
Must also have a secure, separate receiving area for consumables receiving and storage.
An example of a CSSD unit is shown in Figure 21.T

[[File:An example of a small CSSD facility.png|600px|thumb|none|An example of a small CSSD facility<ref>IUSS 2014, https://www.iussonline.co.za/norms-standards/support-services/24-central-sterile-service-department</ref>]]

To be understood: Quality of services, eg. water (including a source of distilled or ionised water for rinsing of bronchoscopes) and electricity, quality of management, if equipment is appropriate for needs and fit for purpose, what is required of the equipment in the near and far future (relocation?), compliance with S.A. National Standards for CSSD, compatibility of equipment and devices, correct chemicals, maintenance of equipment, training of operators. Although the use of disposable breathing circuits and accessories (masks) should be encouraged, the capacity to disinfect these items if disposable is not available must be considered.

The CSSD must be sized to serve the ACS. Considerations are workload and space requirements. CFSA has extensive [https://www.fidssa.co.za/Content/Images/CFSA_SOP_2018.pdf standard operating procedures] for CSSD.

Workload: Number and type of procedures, number of procedure rooms, eg for bronchoscopy, operating hours, available inventory, volume of work and peak times, degree of mechanization, eg. manual or automated instrument washing, amount of product to be stored – chemicals, barrier wrap, chemical indicators, etc., storage and distribution records, quality records – eg. equipment checks, disposal needs.

Space requirements: Space for separation of clean and dirty, allow for unidirectional movement, allow space to manoeuvre trolleys (queue, pack/unload), reduce lifting and carrying heavy items, reduce awkward movements, allow for tidy work areas. Insufficient space will compromise sterility!

Preference should be given to construction materials and finishes which are suitable for frequent cleaning and tolerant to chemicals, including bleach (sodium hypochlorite). Impermeable flooring, non-slip and smooth washable walls are needed. Joints at walls and floors and coving at wall edge, and exposed drains should be avoided. Worktops should be sealed and should be ergonomically suitable.

Ceiling heights below 2.8m may be vulnerable to damage from humidity Where steam and moisture are generated. Noise – insulation of washer-disinfector and steriliser in technical walls will reduce noise. Lighting: Natural light if possible – windows sealed. High luminance if artificial lighting. Open, slatted shelves for sterile store area. Sinks for manual washing: At least two basins, deep (25cm at least) basins, 91 cm from floor, wide and long enough for the biggest instrument tray or container, water ports for flushing of lumens.

The CSSD space allocation and layout should be determine based on what procedures and which medical devices will be required. A typical [[equipment list is provided here]].

=== Maintenance and cleaning ===
Maintenance and cleaning services must be accommodated with offices located away from clinical areas.

=== Mortuary services ===
The National Department of Health has issued guidance on handling of dead bodies and infectious remains<ref>National Department of Health South Africa, 2020 [https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf]</ref>, which should be applied to ACS. While some guidelines have recommend that bodies of persons who have died from COVID-19 should only be held for a very brief period prior to cremation or treatment for burial<ref>Zhejiang University, 2020 [http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm]</ref>, the WHO holds the view (at the time of writing) that there is no evidence of persons becoming infected from exposure to bodies during normal ceremonial and burial activities. However, appropriate PPE should be used when handling such bodies with additional airborne precautions to be taken during autopsies<ref>WHO, 24 March 2020 [https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf]</ref>.

Either body cabinets or a refrigerated room could be used for body storage.
==== Location and layout of mortuary service ====
It is likely that not all alternative care sites will have a mortuary. Those without a mortuary must have a holding room that is located away from general access areas. This holding room must be suitably sized and conditioned. A recommended room size is 3.5 m x 3.4 m<ref>IUSS Adult Inpatient Services, 2014, [https://www.iussonline.co.za/docman/document/clinical-services/65-adult-inpatent-services-gazetted/file]</ref>
A mortuary should be located so that it is easily accessible to mortuary staff and related service providers and visitors without presenting either aesthetic, emotional or ethical problems for unrelated staff, patients or visitors. It should be separate from the general facility, allowing access for the family to view a body without passing through any potentially contaminated area of the facility. The visitors’ entrance should be external and completely separate from other access points.
Appropriate routes should be designated so that bodies are not moved through public-access areas.
==== Sizing of mortuary ====
The layout and size of a mortuary are largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.
==== Services ====
The following services are required in a mortuary:
* Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.
* Sluicing facilities are to be provided in both the body-preparation and autopsy areas if they are not a common area.
* Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush-fitted stainless steel grids.
* No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.
* The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.
* Anti-backflow devices should be fitted to the water-supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.
* Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.
==== Finishes ====
Wall and floor finishes should be impervious to liquids and easily cleanable.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Engineering and environmental controls''' ==

=== General indoor environment conditions ===

Existing environmental control systems should be modified to suit requirements in the facility. The following issues should be considered:
* Systems should be set to maximise the introduction of fresh air and maintain the pressure regime (see ventilation).
* The following internal temperature range should be maintained 19 - 24oC.
* Cooling systems should be able to cater for projected internal heat gains from people, lighting and equipment. Indicative heat gains in treatment areas are 8W/m2 from people, 15W/m2 from lighting and 3 W/m2 equipment and in critical care areas 16W/m2 from people, 15W/m2 from lighting and 60W/m2 equipment.
*As heat gain can vary widely between items of equipment, heat gain and utilisation rates for equipment should be obtained from the manufacturer to establish this more accurately.

=== Solid waste from ACS ===
According to the National Department of Health COVID-19 Environmental Health Guidelines
“All solid waste from the facility should be regarded as potentially infectious material and therefore appropriate precautions should be taken". The management of healthcare risk waste (HCRW) should follow the correct identification segregation, storage and disposal processes as indicated in SANS 10248-1.

* HCRW is segregated at the point of generation and shall be containerized to minimize the risk of contamination.
* Waste generated from patients in isolation or quarantine in a designated facility health facility is treated as health care risk waste (HCRW) as per SANS 10248-1-2008.
* The HCRW is properly packaged in a sealed, leak and puncture-proof containers/ boxes.
* The HCRW is labelled with the biohazard symbol/ sign and marked “Corona virus or COVID-19”.
* The HCRW is stored separately from other waste generated.
* The collection, transportation, treatment and disposal is provided by only an appointed/ appropriate contractor/ service provider, however, ensure that waste is safely stored until the health care waste management company can pick it up and that the company knows and acknowledges that waste was generated by suspected or confirmed COVID-19.
* The waste management company collecting must ensure that and treated and disposal is conducted at license waste treatment/ disposal facilities .
* All personnel or staff in contact with patients must be geared with appreciate personal protective equipment (PPE’s) at all times to prevent exposure or risk to health.
* Monitoring should be done at such facilities.
* All, bags, bins and boxes must be adequately sealed, as not to leak any fluids, and must be wiped down with 0.05% chlorine solution

Measures developed should consider the following.
* Develop a waste management plan following national guidelines and best practice standards for the disposal of medical waste (WHO, 2020).
* Establish procedures with medical waste service providers to regularly pick up the waste and dispose of this safely.
* Provision should be made for 5kg of solid waste per bed per day and this should be monitored and supplemented where it appears this may be inadequate.
* Ensure that access to waste is secure and controlled, for instance, by using lockable waste 1000l containers kept in a location that can only be accessed by health facility and nominated service delivery staff.
* Vermin control programs must be implemented throughout the site with HCRW collection points prioritised
* Provision for safe cleaning and disinfection of reusable containers should be provided. Cardboard, single-use HCRW boxes are removed from site and incinerated.
* Waste must not be allowed to accumulate or be stored inappropriate or unsecured containers.

== '''Engineering Services''' ==
Engineering services include patient services, ventilation, electrical power, water, medical gases, oxygen, compressed air, vacuum, lighting, and fire safety that support the needs of the patients and medical staff under normal and emergency situations. Good practice standards are provided in:
* IUSS Building Engineering Services<ref name = "IUSSBES">IUSS 2017, [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file]</ref>
* NHS Nightingale Instruction Manual<ref name="BDP2020">BDP 2020, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf]</ref>.
The guidance below draws on these and other manuals and standards. 

=== Building ventilation ===
==== Mechanical ventilation ====
While SARS-CoV-2 RNA has been detected in aerosol form, in experimental mechanical aerosolization studies, it is primarily spread through droplet and contact spread and the potential for airborne transmission is thought to be low.
However, the following advice is provided by ASHRAE regarding HVAC systems in general spaces (not specific to healthcare):
Effective high levels of ventilation must be achieved in the facility. Existing ventilation systems should be tailored to suit internal layouts and requirements and the following measures should be taken.
* Mechanical systems should be set to maximise fresh air supply to the facility. There should be no recirculated air without HEPA filtration or other validated decontamination processes.
* A pressure regime should be established, as shown in figure 2, to 'push' air from clean areas, to dirty areas and then out of the building.
* A clean air supply of over 10 L/s per person should be targeted for odour control.
* Fresh air supply shall not be located near patient beds to avoid drafts in winter.
* Extraction points can be located near patient beds in isolation wards or at a high level in long-stay wards. Short-circuiting of air between high-level supply and extraction is a performance risk in winter.
* Noise from ventilation systems and fans shall be below 45 dBA
* Protected lobbies, internal partitions, door arrangements, fans and extracts should be used to maintain the pressure regime and airflow as indicated in the diagram below.
 

[[File:Ventilation in temporary facilities.png|600px|thumb|none|Ventilation in temporary facilities<ref name="BDP2020"/>]]

==== Natural ventilation ====
The airflow direction between naturally ventilated zones may fluctuate according to the wind direction. This is not of concern within and between contaminated zones where occupants are either protected with mandatory PPE or confirmed to be infected with disease strains similar enough so as not be able to reinfect others. Where levels of occupant susceptibility to an airborne disease is significantly different, the less susceptible areas (such as PUI areas and uncontaminated areas) shall be protected from the naturally ventilated and contaminated areas by mechanical ventilation systems with a capacity sufficient to overcome the expected natural ventilation pressure fluctuations (typically 5-15Pa). Where such mechanical ventilation systems are not feasible or expected wind pressure is too great, zone adjacently must be avoided.

===Ultraviolet germicidal Irradiation===
The application of Ultraviolet Germicidal Irradiation (UVGI) for room air disinfection is well understood and is proven to be effective in the disinfection of microorganisms including M. tuberculosis (TB) in air. UVGI should, therefore, be considered as a valid element in indoor airborne infection control strategy for high volume settings. Studies have demonstrated the importance of good vertical air mixing in the room, and the safety of UVGI application. In areas where UVGI is indicated, the design and development of UVGI systems should be in accordance with the [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]<ref>van Reenen et al,2019 [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]</ref>

=== Electrical power ===
Sufficient and reliable power must be available at the facility for envisaged medical equipment, medical gases, lighting and building ventilation equipment. Power installations for the temporary facility can be divided into three zones as indicated below. These are existing services, the temporary service zone and services in each bay.
The following should be considered by competent engineering professionals.

=== Existing services ===
*Capacity: Evaluate whether sufficient power to accommodate envisaged medical equipment, additional lighting and heating, building ventilation and air conditioning can be provided. If existing capacity is insufficient, investigate if it is possible to route additional power from additional locations/transformers around the site or from adjacent sites.
* Safety: The existing electrical distribution network must be able to supply the required equipment load. If this is insufficient/appears unreliable, identify how this can be supported.
* Resilience: Evaluate back-up power and a UPS capacity against essential services demand. If existing capacity is not sufficient, source and establish temporary service capacity.

=== Temporary service zones ===
*Identify locations for temporary service zones where equipment can be located.
*Ensure that equipment and maintenance access is safe and easy.
*Ensure that all distribution boards, circuit breakers and cables are clearly labelled.
=== Services in each bay ===
*Provide pre-wired power strips/trunking as per bay requirements.
*Check that these include sufficient electrical outlets and service points for envisaged equipment.
*Ensure that trunking will carry required equipment loadings. The IUSS Building Engineering Services Guide can be used to check requirements<ref name = "IUSSBES"/>.

[[File:Layout_of_power_in_a_temporary_installation.png|600px|thumb|none|Layout of power in a temporary installation <ref name="BDP2020"/>]]
----

=== Water ===
Water points are needed for handwashing, showers and cleaning. The following issues need to be taken into account.
==== Supply ====
Onsite cold water storage, dedicated to the domestic water requirements of the facility, should be provided. A minimum usable volume of 500 litres per bed should be available.
Hot water storage and consumption should be confirmed by an engineer, as follows:
*Storage 25 L per bed.
*Consumption 180 L/bed.day W/O laundry; 250L /bed. day W laundry.

==== Handwashing ====
See infection control for clinical wash-hand basins
==== Showers ====
Showers for staff coming off shift should be available. Staff flow routes exiting contaminated treatment areas should pass through gowning and shower areas.
----

=== Medical gases, oxygen and vacuum (suction) ===
Medical gases, oxygen and vacuum services will be required in the facility. Mobile gas supply requires piping between supply and patient and clutter floor space. Preferably used fixed installations for patient rooms/cubicles, if possible.

System capacity and point of use pressures and consumption rates are to be ensured at all points. WHO provides technical guidance on [https://www.who.int/publications-detail/oxygen-sources-and-distribution-for-covid-19-treatment-centres oxygen sources and distribution]. 
[[File:Medical gas service layout.png|6oopx|thumb|Medical gas service layout<ref name="BDP2020"/>]]
The following points should also be taken into account.
* For centrally supplied medical gas and vacuum services, system resilience and availability must be ensured.
* Compressors, tanks, accumulators, VIEs, headers and controllers must be secured from uncontrolled access.
* Where possible, gas piping should be reticulated below floors or in ceilings to ensure protection from tampering, damage and ease of access.
* Where reticulation is within open areas, high-level reticulation with point-of-use droppers is advised. Low-level reticulation within rooms is to be avoided.
* Flexible piping can be used, ensuring it does not present a contamination or fire risk and should comply with local regulations. Special care should be taken with flexible O2 piping, keeping it to a minimum.
* Vacuum piping may be contaminated, where point-of-use filtration and collection systems fail. Precautions should be taken when demounting or disconnecting temporary vacuum lines.
* Ensure that oxygen pipelines are designed to provide sufficient flow to all oxygen points in the facility. In terms of utilities, oxygen and medical air would be required. A temporary vacuum point can be provided by mobile medical vacuum units distributed throughout the unit.
* Mobile medical air supplies should be considered where reaching piped specifications are not feasible. Where flexible hoses are used for oxygen and medical air special precautions need to be taken. Flexible oxygen piping must be chemically safe for O2 use. Where perishable flexible piping is used for medical air, terminal filtration at the point-of-use may be required at point-of-use. Especially for long-term use.
* Electrical and gas services can be reticulated against pipe racks or boards fixed to the bed-heads for head to head bed arrangements.
* Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.
* Gas service outlets to be labelled and colour-coded with 3mm lettering.
* SANS 7396-1 should be used to specify the requirements from design to commissioning of medical gas and vacuum systems.
* Medical gas and vacuum pipelines shall be marked per SANS 7396-1 and ISO 5359, as applicable.
* Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.
* SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.
* Plain-ended copper tubing for low-pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.
* Laboratory gas taps and valves shall be marked as described in SANS 10140-4.

=== Lighting ===
Existing lighting systems may need to be modified to suit the clinical requirements in the facility. High bay lighting presents inadequate colour rendering quality for the accurate detection or easy diagnosis of certain clinical conditions. This needs to be evaluated in the selection of supplementary lighting systems.
*Lighting levels should be provided in line with the indoor lighting levels recommended in the Table 6 of IUSS Building Engineering Services .
*Mobile task lighting systems may be adopted in the serious and critical stay wards to supplement incorrect lighting quality.
*Emergency lighting and illuminated emergency egress signage should be linked to the back-up power system.
*External security lighting in external parking areas and spaces around the building should be enhanced to ensure the security of medical staff who need to change shifts at night.

=== Fire safety ===
A functional fire alarm system should be available to support the patient care setting. Fire is a very real threat due to the possibility of an oxygen-enriched atmosphere developing so ventilation is crucial.
The use of temporary facilities for medical care should note the following fire risks (NHS, 2020):
*Patients may have a very high dependency.
*Areas are not specifically designed for patients and do not meet guidance on fire compartmentation and progressive horizontal evacuation.
*Large numbers of patients supplied with oxygen up to 10 litres per minute.
*Possibility of oxygen concentrations exceeding those generally found in the atmosphere- less risk if effective ventilation or large volume i.e. high ceilings.
* Possibility of storage, in excess of 40 litres, of alcohol-based chemicals (such as hand-rub), necessitating a flammables cabinet on site.
*Staff who may not normally work together .
*Staff who may not be familiar with the area.
*Staff not trained in fire safety, progressive horizontal evacuation or oxygen isolation for the specific area.
These factors should be taken into account in fire risk assessments which should then address significant findings in an action plan. Fire assessments should be undertaken by a qualified person and shared with operations and building management staff within the facility. Measures developed should include:
*An automatic fire detection system
*An emergency egress plans are prepared that include patients who have a very high dependency.
*Signage, notices and lighting are installed and are working effectively.
*Management processes are in place to minimise the risk of fire from ignition sources, fuels and oxygen.
*Staff are trained and a fire safety guide sheet for staff is developed and issued.
*Emergency egress routes are kept clear.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Additional Resources''' ==
=== [[Directory of Service Providers|A Directory of Service Providers can be viewed here]] ===

=='''References'''==
<references />

[[Category:COVID-19| ]]
[[Category:Alternate Care Sites|Alternate Care Sites]]

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[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19|(Return to Top)]] 
----

Infrastructure Guidance for COVID-19/Alternate Care Sites

2020-05-08T08:46:25Z

Peta: /* General Indoor Environment Conditions */

[[Infrastructure Guidance for COVID-19|Return to Infrastructure Guidance for COVID-19]] 

== '''Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19'''==

This guidance work was initiated under the project titled: 
''Reducing Nosocomial and Community-Acquired Tuberculosis by Strengthening the Capacity of the South African Department of Health to Improve Implementation of Infection Control and Waste Management at All Levels of the Health System Under the President's Emergency Plan for AIDS Relief (PEPFAR)'' 

== '''Introduction''' ==
=== Purpose and approach ===
The global pandemic of COVID-19 caused by the coronavirus, SARS-CoV-2 is likely to result in a surge in need for medical care for Severe Acute Respiratory Syndrome (SARS) in South Africa. Considering the course of the pandemic in other countries, it is anticipated that South African hospitals will not have sufficient capacity to cope with the surge of persons requiring medical attention and that surge capacity via alternate care sites (ACS) will need to be established.
Surge capacity, contemplated here is not the frequent emergency department overcrowding experienced by healthcare facilities (e.g. Friday/Saturday night emergencies) or local casualty emergency that might overcrowd nearby facilities and have little to no impact on the overall healthcare delivery system. It is when a catastrophic event occurs and the affected population seek medical care from existing local healthcare facilities, causing healthcare infrastructure to become exhausted due to excess in demand. During a healthcare surge, the standard of care will shift from focusing on patient-based outcomes to population-based outcomes, and providers should anticipate “a shift to providing care and allocating scarce equipment, supplies and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals.”<ref>[https://asprtracie.hhs.gov/technical-resources/resource/491/altered-standards-of-care-in-mass-casualty-events Health Systems Research Inc., 2005]</ref> 

Surge capacity can be temporarily established in non-traditional environments, such as hotels, exhibition halls, community halls, and as field hospitals, on open spaces. 

In the context of this document, a quarantine site is a facility for patients who do not require continuous professional medical care, while an ACS is defined as a temporary facility that can provide continuous medical care for SARS. This document provides principles and considerations, high-level guidance for minimum requirements and examples for ACS. 

While an extensive set of health facility guidelines does exist<ref>[https://www.iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-servi IUSS Building Engineering Services (2017)]</ref>, these are applicable for conventional facilities and thus include services and guidelines that are not necessarily relevant to the treatment of a novel, highly infectious pathogen, with pandemic effects. Moreover, these do not provide well for the rapid and temporary establishment of facilities. 

In order to formulate high-level guidance, [[as invited by Business for South Africa]], the team reached out to professional industry bodies for inputs, in particular the South African Institute for Architects (SAIA), The Gauteng Institute for Architects (GiFA) [https://www.gifa.org.za/ Gauteng Institute for Architecture] and the [http://www.safhe.co.za/ South African Federation of Hospital Engineering (SAFHE)], by inviting input via a 36-hour research charrette. Relevant historical and contemporary literature was consulted, precedents identified and critically reviewed. An interaction with the team at Wuhan responsible for makeshift hospitals and emergency infectious diseases hospitals, Central-South Architectural Design Institute, was arranged with assistance of the Chinese Embassy. Material from the [[Infrastructure Unit System Support|Infrastructure Unit System Support (IUSS)]], international literature and guidance and input gathered from the broader architectural, engineering and healthcare professional communities was synthesised and moderated by the CSIR team. The draft was reviewed by an expert review panel. 
=== Acknowledgement of contribution ===
The contributions to the initial version of this were gratefully received. [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Acknowledgements|A list of these contributors can be viewed here.]]. 
New contributions are eagerly encouraged along with debate and discussion on the [[Talk:Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites|'''discussion forum.''']] tab above.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Scope and Assumptions''' ==
ACSs as discussed in this document are dedicated, temporary facilities for triage, testing, diagnosis, further referral and treatment of persons:
*suspected of having contracted SARS-CoV-2, (persons under investigation (PUIs)), who are symptomatic and/or are awaiting results,
*or are confirmed to be infected.
ACS will accommodate a variety of clinical, logistical, support and auxiliary services associated with the render of care. ACS will currently not be licensed to provide healthcare services. Since the ACS will operate in a non-healthcare facility, it cannot fully replace a hospital setting and its prime objective is to manage the patient load until the local healthcare system can meet demands. 

=== Exclusions ===
Quarantine facilities are accommodation facilities where a member of the community can remain for the duration of their isolation period. This is typically temporary housing for a cohort of people who do not need intensive medical attention but who cannot stay at home. Patients can take care of themselves and need limited monitoring by medical staff. Quarantine: Containing presumptive-case patients from each other and the general population.
Quarantine facilities – that is for asymptomatic persons who are in the community in self- or imposed isolation, but not displaying symptoms, or who are symptomatic, but are able to safely recover without clinical intervention and do not need continuous medical observation are not considered in this document.

=== Service regime ===
The following assumptions are made with respect to services under consideration.
* Temporary - limited to the part of the pandemic when the “conventional” hospital platform cannot meet demand. To be dismantled, thereafter.
* Uncomplicated, dedicated COVID-19 care is to be prioritised for ACS.
* Patients with comorbidities, paediatrics will be prioritised for conventional facilities, and only accommodated in ACS as a matter of last resort.
* 24 hour, 7 days a week operations. 

=== Assumed mechanism of transmission ===
Transmission of SARS-CoV-2 is understood to be from person to person firstly by [https://en.wikipedia.org/wiki/Transmission_(medicine)#Droplet_infection droplet] transmission, then by the [https://en.wikipedia.org/wiki/Transmission_(medicine)#Direct_contact contact] route and finally via airborne [https://en.wikipedia.org/wiki/Transmission_(medicine)#Airborne_airborne transmission] during or following mechanical aerosolisation. Water transmission risks are minor, occurring in special [https://en.wikipedia.org/wiki/Transmission_(medicine)#Fecal%E2%80%93oral Fecal-oral] circumstances. Reclassification of transmission mechanisms may nullify some of the approaches presented in this guidance. 

=== A call for strategic coordination ===
This document focusses on infrastructure requirements. These provisions are meaningless without staffing, equipping and resourcing. Whilst staffing, equipping and resourcing are not the focus of this document, these are likely to emerge as key constraining features. Resource constraints are likely to become acute during this pandemic. Doctors and nurses are already in critical short supply in South Africa and internationally, and are themselves susceptible to COVID-19 infection. Equipment and consumables are in short supply with heightened global demand, reduced manufacturing capacity and limits in trade flows. This necessitates strategic coordination, proactive planning, options appraisal and prioritisation. 

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Status Quo''' ==
=== Rationale and transmission status ===
According to the [https://en.wikipedia.org/wiki/World_Health_Organization World Health Organisation] (WHO), based on the largest cohort of COVID-19 patients, about 40% of patients with COVID-19 may have mild disease, where treatment is mostly symptomatic and does not require inpatient care. About 40% of patients have moderate disease that may require inpatient care; 15% of patients will have severe disease that requires oxygen therapy or other inpatient interventions, and about 5% have critical disease that requires the patient to receive mechanical ventilation. However, the evolution of the outbreak in some countries has shown a higher proportion of severe and critical cases and the need to rapidly increase surge capacity to prevent rapid exhaustion of biomedical supplies and staff. In some countries, doubling rates of cases every three days has been observed<ref>WHO-2019-nCoV-HCF_operations-2020, [https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf]</ref> 

South Africa has a high burden of disease, with a high prevalence of [https://en.wikipedia.org/wiki/HIV/AIDS_in_South_Africa HIV and TB]. Although evidence is yet to emerge of the effect of SARS-CoV-2 on a population with these pre-existing conditions, there is reason to proceed with caution<ref>The Conversation 2020, https://theconversation.com/tb-hiv-and-COVID-19-urgent-questions-as-three-epidemics-collide-134554</ref>. There is a potential direct and indirect benefit of ACS to people living with HIV and TB, as well as to general public health and the health system preservation. 

With the travel lockdown in place, and continued transmission, it appears that South Africa is on the cusp between cluster transmission and community transmission according to WHO’s classification, shown in the [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites#Key_clinical_and_infection_control_activities_for_different_transmission_scenarios_.5B3.5D|table below]], indicating that preparation should include temporary hospital facilities and mass critical care.

==== Key clinical and infection control activities for different transmission scenarios <ref>WHO 2020, [https://apps.who.int/iris/handle/10665/331492 https://apps.who.int/iris/handle/10665/331492]</ref> ====
{| class="wikitable"
|-
! !! '''No Case''' !! '''Sporadic Case''' !! '''Clusters of Cases''' !! '''Community Transmission'''
|-
| Faculty Space, Including for Transmission|| Usual Space. Enhanced Screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards). || More patient care areas re-purposed for COVID-19 within the health system, especially for severe cases || Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Staff|| Usual space. Enhanced screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards)||More patient care areas repurposed for COVID-19 within the health system, especially for severe cases||Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Supplies||
*On-hand supplies. Equip wards for COVID-19 treatment.
*Identify essential equipment and supplies, including oxygen.
*Prepare expanded local supply chain
||
*Expanded inventory of supplies with detailed protocols for use.
*Activate expanded local supply chain.
*Prepare national supply chain.
||
*Conservation, adaptation, selected re-use when safe.
*Activate contingency planning and procurement for essential equipment and supplies.
*National supply chain.
*Prepare expanded supply chain at the global level
||
*Activate contingency planning should critical equipment be in short supply.
*Determine allocation of lifesaving resources for HCWs and patients.
*Activate expanded global supply chain
|-
| Standard of Care|| Usual care with enhanced awareness and recognition of immediate needs for first COVID-19 patients|| Usual care and treatment for all patients, including those with COVID-19||Identify context-relevant core services. Shift service delivery platforms. Consider reduction in elective patient encounters, including elective surgical procedures.|| Mass critical care (e.g. open ICU for cohorted patients).
|-
| Care areas expansion|| No requirements for expansion|| Designate 10 beds per suspected COVID-19 case|| Expand COVID-19 patient care areas by a factor of 35 ||Expand COVID-19 patient care areas by a factor of 58
|}

=== Quantification of need ===
At this time there are various parallel initiatives aimed at forecasting the South African epidemic, quantifying the projected need for facilities, and a shortfall in existing capacity. At this time, there is no consensus on this. This section will be updated as further data becomes available.
ACS will prioritise mild to moderately affected COVID-19 patients where basic, targeted medical care will be provided. Should patients’ needs evolve, requiring escalation of care, then the transfer of patients from ACS sites to conventional sites of care will be needed as a matter of course, bringing with it logistical challenges and risks. In the event that the conventional hospital platform is unable to cope, ACS will have pressure to provide care for severe and critical patients, and finally for patients with comorbidity and special requirements, such as paediatrics, persons living with HIV (PLHIV), TB patients and pregnant women. The following pragmatic approach, aligned with the WHO recommended strategic approach, is suggested.
*ACS should preferably be identified with space for expansion.
*The set-up should be done so that levels of care can be upgraded to higher levels of uncomplicated care.
*A secondary upgrade for more diverse package of care may become necessary.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Strategic Approach''' ==
According to WHO, clinical interventions must be put into place immediately and then scaled up according to the epidemiologic profile.
[[File:COVID-19 Resource allocation.png|none|thumb|600px|right|WHO Strategic approach to clinical care]] 
Under this declared state of disaster, the clinical care strategy which cannot be accommodated within existing facilities, can, on a temporary basis be hosted in ACS:
*Within and around existing healthcare facilities, via reconfiguration and/or augmentation.
*In existing non-healthcare buildings suitable for repurposing, such as universities, hotels and conference centres, warehouses, gyms, hostels etc.
*On open fields, including paved parking areas with rapidly constructed, dismountable structures, such as modular tented structures or using rapid modular construction techniques. 

ACS will provide isolation, general (non-acute) care for patients with mild to moderate symptoms and as required, acute care for patients with severe symptoms. Containing confirmed-case patients from general population. Confirmed-case patients can be housed together en masse, while presumptive-case patients must be individually quarantined.
As shown in the WHO Strategic approach to clinical care, the WHO recommends a range of services to meet patient need (''Citation needed''). General (non-acute) care ACS model is designed for minimal acuity patients requiring minimal activities of daily living support (e.g. COVID-positive with minimal symptoms or require <2L of oxygen). Acute care ACS model is designed for higher acuity patients requiring closer monitoring or respiratory support (e.g. COVID-positive with pneumonia or respiratory distress requiring ventilator support). Paediatric patients are to be accommodated in separate wards, where strictly controlled visitation may be allowed. 
As a preliminary estimate, the following ratios of service is proposed:
[[File:COVID Ratios of Service.png|none|thumb|600px|center|COVID Ratios of Service]]

{| class="wikitable"
|-
! '''Case severity, risk factors<ref group="Notes"> Test suspect COVID-19 cases according to diagnostic strategy</ref><ref group="Note"> Known risk factors for severe COVID-19: age over 60 years, hypertension, diabetes, cardiovascular disease, chronic respiratory disease, immunocompromising conditions.</ref>''' !! '''Recommendations'''
|-
|Mild || Patient should be instructed to self-isolate and contact COVID-19 information line for advice on testing
and referral.
|-
|Moderate, with no risk factors ||Test suspected COVID-19 cases according to diagnostic strategy. Isolation/ cohorting in:
* Health facilities, if resources allow;
* Community facilities (e.g. stadiums, gymnasiums, hotels) with access to rapid health advice
(i.e. adjacent COVID-19 designated health post/EMT-type 1, telemedicine)
*Self-isolation at home according to National guidance
|-
| Moderate, with risk factors || Patient should be instructed to self-isolate and call COVID-19 hotline for emergency referral as soon as possible
|-
|Severe || Hospitalization for isolation (or cohorting) and inpatient treatment.
|-
|Critical|| Hospitalization for isolation (or cohorting) and inpatient treatment.
|}

=== Notes and References: ===

<references group = "Note" />
<references />

=== Typology dictates & case studies ===

[[File:NHS Nightingale Hospital London.png|thumb|NHS Nightingale Hospital London <ref name="NHS Nightingale Hospital London">Coronavirus: Building NHS Nightingale Hospital London, 2020 [https://www.bbc.com/news/in-pictures-52092253 https://www.bbc.com/news]</ref>, ]]
To meet the requirements set out in this guidance, prospective “host” sites should be carefully evaluated. The type of “host” site selected will strongly influence or dictate the choice of ACS service model.

No site is likely to meet all requirements and recommendations set out in this document. Adaptations and compromises will be necessary. Services should be provided on site where it is pragmatic to do so, for example where similar services are provided. Outsourcing can also be practical/feasible for some services, such as laboratory services, catering and laundry, provided suitable logistical arrangements can be made.

Some typological responses and service models are set out in precedent examples, shown below. The examples demonstrate that a variety of host settings are workable, provided that the appropriate utility can be contrived.

=== Pragmatic approach ===
Other than in metropolitan areas, co-location of ACS on the premises of, or adjacent to existing healthcare facilities will often be preferable because this is where intensivists and specialist clinical staffing will be available, and support services may be well established. Nevertheless, augmenting capacity at existing facilities should take into account current workloads and capacity to ensure that the COVID-19 surge disrupts normal service provision as little as possible, including continuity of care for patients with chronic conditions and TB and HIV patients. 

*'''[[Infrastructure Guidance for COVID-19/Alternate Care Sites/Case Studies|SARS ACS Precedents and Case Studies can be found here]] '''

=== Notes and References ===
<references />

== '''ACS Infrastructure Planning''' ==

=== Establishing a team ===
A planning team should be formalised to establish the minimum planning and operational requirements for the ACS and to liaise with the local community. The team should include individuals with expertise in the following areas (ideally with knowledge of healthcare delivery under emergency conditions):
*Disaster response / emergency management coordination,
*Clinical care and staffing,
*Infection Prevention and Control practitioners must be involved in all stages of planning, commissioning, in-use, and decommissioning of the facility
*Facility set-up, operations and management,
*Security,
*Transport (patient, staff),
*Engineering and project management,
*Procurement and coordination of supplies, equipment and pharmaceuticals, and
*Community liaison to ensure that concerns of the adjacent population on understood an addressed.
It is important to ensure compliance with health, safety and building regulations, by ensuring the involvement of relevant local authorities. Stakeholder engagement should be formally documented. Concerns and grievances should be systematically addressed.

=== Structural integrity and operational responsibility ===

'''Structural modifications:''' ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered. 

'''Competent person:''' All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed. 

'''Asset responsibility:''' Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented. 

'''Integrity and responsibility'''

'''Structural modifications''': ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered.

'''Competent person''': All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed.

'''Asset responsibility''': Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented.

'''Decommissioning''': Decommissioning of the facility shall be assigned to the competent person discussed above. All residual structures upon decommissioning shall comply with the National Building Regulations. Upon decommissioning, removal of equipment shall be the responsibility of the owner. An infection prevention and control practitioner should be engaged in the decommissioning phase to oversee terminal cleaning and disinfection of equipment and premises.

'''Closure''': Once all patients can be safely discharged or transported back to existing facilities for continued care and there are no ongoing healthcare surge capacity needs, the ACS can be closed. Shut down of an ACS will require decommissioning, identification of new homes or storage for equipment, and termination of ongoing contracts or arrangements. Shut down should be expedited so that the facility can quickly be returned to the control of the existing owners and returned to its usual function.

Action checklist items for ACS closure should include, but not be limited to, the following:
*conduct a site walk-through with the facility owner when shutdown activities are completed to ensure that terminal cleaning and disinfection of supplies and premises, removal of equipment and supplies, and other surge closure activities have been completed to the owner’s satisfaction.
*perform medical records storage procedures.

== '''Site Selection''' ==
When selecting a site, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital can be utilised to determine whether the site is suitable for a 100, 1000 or 2000 bed facility, as required. The following indicative minimum site sizes are needed:
*100 Bed ACS/ hospital conversion, requires ± 4 300 m2
*1000 Bed ACS/ hospital conversion, requires ± 17 600 m2
Evaluation should be done by examining plans (if available), satellite images, drone images, scans and by physical inspection (walkabout). A comprehensive photographic survey should be undertaken and retained for record purposes on the site inspection. This will serve as an audit record and may assist in returning the site to its original function on ACS decommissioning and closure. When scrutinising documents and conducting site inspections to confirm the suitability of a site to host an ACS, the following criteria should be taken into account.
=== Criteria ===
*Affordability (costs, including operational costs known and budget identified),
*Sufficient physical space and capacity to house the immediate need, with the potential to accommodate physical space requirements. For example, open site should not be sloping,
*Legal rights and encumbrances, including renewal opportunity,
*Good access to highway and main roads,
*Well secured perimeter and limited controlled access points,
*Proximity to other hospitals and care sites,
*Accessibility for key staff and public transport,
*Good vehicular access around the site to set up temporary equipment such as back-up generators,
*Free from clear and present danger,
*Outside attenuation zones, floodplains,
*Outside high wind zones,
*Structure in good repair,
*Effective onsite facilities management team who understand how systems work,
*Potential for expansion, if required,
*Access to sufficient capacity for
**potable water,
**adequate sewage,
**telephone,
**internet access with sufficient bandwidth,
**electricity,
*A zone for cleaning, disinfection, and decontamination of equipment at least 15 metres away from occupied areas with access to water, a hard impervious surface and drying areas in the sun, with runoff discharge into the sewer and not into marine ecosystems or the environment. Include area for cleaning and storage of cleaning equipment.
*Likelihood of acceptance of hosting an ACS by the adjacent and local community

=== Desirable ===
*Durable, cleanable surfaces,
*Large open spaces that can be converted to accommodate temporary structures,
*Good ventilation,
*On-site kitchen and laundry,
*Housekeeping staff (chemical and equipment storage, lockers, rest facility, administration office),
*Space conducive for staff respite area and locker rooms,
*Amenities with universal access,
*Fire protection safety and equipment,
*Elevator access for patients if the building has more than one floor,
*Capacity for expansion, and
*Accessible to at least two roadways to provide continued access in the event that one roadway becomes blocked on inaccessible.

== '''Infection Prevention and Control''' ==
General guidance for COVID-19 [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|Infection Prevention and Control]] can be accessed [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|here]] 

Infection prevention and control in the context of COVID-19 should respond to transmission routes of primary concern for the pathogen of interest (droplet and contact transmission, and management of risk waste) as well as infection risk of a general nature (water and sewerage, airborne transmission – under high TB/HIV burden, and general waste).
In addition to satisfying [https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html standard precautions for all patient care], transmission-based precautions should focus on three pillars: exposure reduction by spatial configuration, operational strategies, and personal protection.
=== Transmission-based precautions ===
'''Droplet and contact spread''': Transmission of SARS-CoV-2 virus occurs via droplet and contact spread. The virus has been shown to persist on surfaces for extended periods of time and is known to be efficient at infecting people. 

'''Medical waste and linen:''' As SARS-CoV-02 is carried in body fluids and faecal matter, disposal of contaminated items (tissues) and cleaning regimes (spaces, garments, linen) should be accommodated carefully in the workflow design and infrastructure provision. A site-specific waste management plan should be formulated in accordance with a site-specific waste management plan with reference to SANS 10248. 

'''Airborne transmission:''' Under exceptional circumstances, the risk of airborne transmission arises for SARS-CoV-2, as detailed below.
{| class="wikitable"
|-
!Airborne Transmission Risk Factors
|-
|
As SARS-CoV-2 is not considered airborne, respiratory protection against airborne transmission is not considered necessary, except where aerosolisation of particles may be a risk.
According to the CDC
*tracheal intubation,
*non-invasive ventilation,
*tracheotomy,
*cardiopulmonary resuscitation, or
*manual ventilation before intubation and bronchoscopy.
According to doctors in the field also when performing
*COVID-19 diagnostic sampling as patients can be induced to cough and sneeze.
*Suspected or confirmed comorbidity of TB is not an additional risk where correct COVID-19 PPE is applied.

|}
South Africa has a high prevalence of TB and HIV, and therefore, although the risk of COVID-19 transmission via the airborne route is not paramount, there is a high likelihood that undiagnosed TB infectious patients may present at the ACS for treatment. TB triage may be challenging in the ACS as there are symptoms in common (coughing) with COVID-19. This country-specific risk is taken into account in this guidance

=== Additional precautions ===
'''Water and sewerage contamination:''' The International Water Association [[Infrastructure Guidance for COVID-19/Alternate Care Sites/COVID-19 A Water Professionals Perspective|concluded]] that water and sewerage contamination is not considered to be a key risk factor for COVID-19. The panel expressed concern for “how waste and specifically wastewater (medical) would be handled by places (e.g., hostels, hotels) that are used to serve as interim COVID-19 quarantine or testing facilities or accommodation ([ACS]. These are places other than hospitals that are used in the interim for such purposes and do not usually handle wastewater from medical settings. Such facilities should be monitored carefully.” 

== '''Spatial strategies for infection prevention and control''' ==

=== Restricted access and zone control ===
The site will be arranged to establish clear zoning, with a clear restricted zone protocol and access protection. Zones should be deemed to be "contaminated" or "uncontaminated" with clear transition areas between them.

; Contaminated zones
: (also known as "dirty areas") are areas occupied by COVID-19 infected persons, PUIs, equipment, materials and supplies which have come into contact with such persons without yet undergoing a decontamination procedure. These areas will include patient ward areas and ablutions, patient admissions (including ambulance drop-off) and the associated clinical areas. Staff rest and dining facilities should be outside the contaminated zone. Limited stock for immediate use should be kept in the contaminated zone. Layout designs should consolidate contaminated zones as far as reasonable, and avoid uncontaminated zones as islands in contaminated zones.

; Uncontaminated zones
: (also known as "clean areas") are areas not generally occupied by PUIs or confirmed COVID-19 infected persons. Equipment, materials and supplies in these areas have not yet come into contact with contaminated zones or have undergone a decontamination procedure. These will include clinical management planning rooms, stock rooms, bulk stores, pharmacy, laboratory areas, kitchen and laundry.

; Transition zones
: (also known as intermediate zone) are the spaces through which transfer of people and goods from uncontaminated to decontaminated zones, and vice versa, occur. Materials from the contaminated zone should be decontaminated or contained in the transition zone. The transfer of goods and persons should be highly ritualised and, as far as possible, traffic across transition zones should be minimised. Transition areas should be strategically located to serve this function. Separation of in-going and out-going transfer of goods and persons is preferable. Transition areas include ambulance, trolley decontamination, CSSD, laundry and waste bagging areas, patient locker area and staff change areas with spaces for donning and doffing of PPE.

=== Site layout and master-planning ===
Spatial configuration and layout can ensure unnecessary cross-over of function is avoided. This entails the systematic separation of functions and the managed transition between activities to facilitate consistency of care, an orderly, efficient work environment, less waste and reduced risk for improved outcomes. To achieve this, functional relationships should first be considered at the site level before being considered at the building level. 

<gallery mode=packed heights=300px style="text-align:left">
Layout for a SARS facility, clustering functions with minimised cross-over.png|center|thumb|Layout for a SARS facility, clustering functions with minimised cross-over <ref name="Layout1">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Layout_for_a_Patient_cohorting_strategy.png|center|thumb|Layout for a Patient cohorting strategy <ref name="Layout3">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Tygerberg Hospital virus triage unit site layout.png|center|thumb|Tygerberg Hospital virus triage unit site layout <ref name="Western Cape Provincial Government, 2020a">Western Cape Provincial Government, 2020 a</ref>
</gallery>

The WHO's Clustering Layout <ref name="Layout1"/> and Tygerberg Hospital virus triage unit<ref name="Western Cape Provincial Government, 2020a"/> show worked examples of building and site layouts, which are configured with these principles, respectively. '''Cohorting''' is defined as clustering patients with similar or compatible clinical needs together for risk reduction, acuity, efficiency and quality management, as illustrated in WHO's Cohorting Layout <ref name="Layout3"/>

=== Workflow ===
Within individual functional zones, the workflow activities can be arranged to proceed from clean procedures to contaminated procedures. In the example below, the staff arrival, PPE donning, doffing and patient flows are worked to have controlled interaction and minimised cross-over

<gallery mode=packed heights=400px >
ACS HCW Flow.png |ACS Health Care Worker Flow
COVID-19 Workflow in small unit.png |COVID-19 Workflow in Small Testing Unit <ref name="Western Cape Provincial Government, 2020b>Western Cape Provincial Government, 2020 b</ref>
COVID-19 Workflow in large unit.png |COVID-19 Workflow in Large Testing Unit <ref name="Western Cape Provincial Government, 2020b"/>
</gallery>

As far as possible, a single direction flow of clean to dirty is recommended for all processes: support services, supply and waste.
The Small ACS unit workflow diagram<ref name="Western Cape Provincial Government, 2020b"/> illustrates the recommended separation of access and exit, separate waiting seats, for persons who may be COVID-19 infected. Separate spaces are provided for donning and doffing PPE. Staff change areas are provided.

In the Large ACS unit workflow diagram <ref name="Western Cape Provincial Government, 2020b"/>, there is a clear separation between staff areas and patient areas. Waiting seats are set far apart to reduce transmission risk. Staff change rooms are provided near the point of entry to the facility for staff to change from street clothes into medical work clothes. To prevent work clothes worn inside the facility from contaminating street clothes, these are kept in separate lockers. A step-over barrier from dirty to clean sides of the change room is helpful to enforce a mind-set of avoiding cross-contamination. Bins for contaminated garments are to be provided in change rooms. Shower facilities are to be provided for staff.

== '''Operational Strategies''' ==
=== Cleaning, disinfection and decontamination ===
Surface and substrate specification, and detailing of all areas should, as far as possible, allow for frequent:
*Cleaning with detergent and water.
*Disinfection with 75% alcohol solution (metal surfaces).
*[https://en.wikipedia.org/wiki/Sodium_hypochlorite Sodium hypochlorite] (1,000 ppm)/ Household bleach.
*Disinfectants listed on the EPA List N<ref>The United States Environmental Protection Agency, [https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 List N: Disinfectants for Use Against SARS-CoV-2 (Last Visited 2020) ]</ref> (for non-critical environmental cleaning).
*High-intensity ultraviolet surface disinfection (UV-C).
*Decontamination and sterilisation of clinical equipment.

=== Goods and waste management ===
Remove any unnecessary furniture, equipment and paraphernalia from all patient care and clinical areas. Provide a clear, secure space for waste management. Any potentially infectious waste materials generated at the ACS should be considered and treated as medical waste (health care risk waste). The applicable legislation is:
*[https://www.gov.za/sites/default/files/gcis_document/201409/35405gen452.pdf The National and Provincial Health Care Risk Waste Management Regulations].
*[https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf National Department of Health COVID-19 Environmental Health Guidelines.]<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>
Waste disposal bins should be positioned near the exit inside each patient rooms or wards to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another patient in the same room.

=== Materials and finishes ===
Floor materials must be:
*Level,
*Free of dust and oil,
*Impervious and smooth,
*Slip-resistant in wet areas (e.g. patient ablutions).
Smooth, cement screed floors are acceptable. Where hosting facilities have carpeted areas, a risk assessment of factors such as durability, hygiene and decontamination needs to be conducted. In cases where the acceptance of carpeted flooring is contradicted (but other factors make it a compelling option), temporary floor finishes or covering can be investigated.

== '''Personal protection''' ==
=== Hand sanitation ===
Where wash-hand basins are not provided, clinical wash-hand basins should be installed, at the minimum rate of provision of one wash-hand basin per 5 beds. Clinical wash-hand basins (see figure below) have a variety of features not present in standard wash-hand basins, which are preferable for infection prevention and control. Where standard wash-hand basins are provided, an upgrade is not necessary. In all cases, there should be no surfaces and no clutter, equipment or supplies in the vicinity of wash-hand basins, including surgical gloves.
<gallery mode=packed heights=400px>
Clinical hand wash basin.png|Handwash Basin <ref>de Jager 2020</ref>
Portable Wash-hand Basin.png|Portable wash hand basins can be provided in ACS <ref name="BDPa">BDP 2020, NHS nightingale instruction manual, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf</ref>
</gallery>

Where wash-hand basins are not available, portable units can be used, as shown above<ref name="BDPa"/>. Mounted brackets for hand sanitisers are to be provided for every two beds, preferably mounted near the foot rather than the head of the bed and at all common touch points such as entry points at ablution facilities, linen room, sluice, storerooms, medicine rooms/cupboards, near refrigerators, telephones, light switches, at entry/exit doors, etc.

=== Personal protective equipment ===
Donning and doffing points for personal protective equipment, and convenient, safe disposal of consumables to be placed at critical key points when entering patient areas.
----

== '''General transmission mitigation''' ==
=== Water and sanitation ===
To comply with National Building Regulations; Hazardous Biological Agents Regulations and National Department of Health COVID-19 Environmental Health Guidelines<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>.

=== Droplet aerosolisation ===
When designating areas for procedures during which aerosolization and airborne transmission risk is high, the building ventilation must be carefully considered to take into account downstream risks. In particular, consider to where potentially contaminated air, arising from aerosol-generating procedures, is exhausted. In general, air exhausted directly to the outside is diluted and considered safe, unless there are openings to occupied spaces near the exhaust air outlet. 

In the event that potentially occupied spaces will receive partially diluted or undiluted contaminated air, or where this is indeterminate, the aerosolising activity should be designated to an alternate area. In the event that an alternative is not available, some treatment regime (air filtration or air disinfection) is necessary. 

In most naturally ventilated settings, the airflow direction between zones may fluctuate according to the wind direction. Such high-risk spaces should not be adjacent to spaces with high susceptibility rates, such as PUI areas and uncontaminated areas. Contaminated areas should not be directly adjacent to clean areas unless mechanically ventilated. 
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|Guidance on COVID-19 building ventilation design is provided here]].

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Health, Safety and Well-being''' ==
In addition to the infection prevention and control measures discussed above, the following should be provided for health, safety and well-being.
=== General provisions ===
*Minimised and controlled entry and exit points, with suitable control.
*Clearly identified accessible and marked routes for patients, staff, goods and waste.
*Clear designation of restricted zones.
=== Site level provisions ===
*Safe staff parking and arrival of staff via planned and public transport.
*Clearly demarcated parking for people with disabilities.
*Arrival and departure point for patients via public transport, passenger vehicles, and emergency service.
*Limited safe patient parking.
*Supply of goods and removal of waste.

=== Within and between buildings ===
*Entrances with a clear opening width (CoW) of at least 900mm.
*Routes with a minimum width of 2 000mm free of hazards, for example, rubbish bins.
*All clinical, patient and support areas to be accessible by trolley.
'''Ramps''' should be of stable construction, capable of sustaining a mass of 300kg. They should incorporate side lips and the surface should be slip-resistant. Gradients should be as gentle as the circumstances allow. (Recommended maximum 1:20). 
'''Small changes in floor levels''' are not desirable, but where these exist are to be clearly marked with reflective paint/ tape, and lit at night
Elevators between different floors, where patients need access (The recommended minimum lift size for patient trolley/stretcher movement is 1 400mm × 2 400mm, however, this may not be possible). 
'''Pathways''' to be lit at night, where used at night. 
'''Staircases''' must be well-lit at night with non-slip surfaces and secure balustrades. 
'''Doors''', Double doors and automated or push-operated doors to all clinical areas are to be preferred, where these are newly installed or able to be retrofitted. Door closers are to be disabled, where not necessary to reduce touch surfaces. Hand sanitisers to be provided at where high touch common surfaces occur (e.g. wall-mounted at doorways).

=== Signage ===
The appropriate level of information to facilitate legibility, orientation and wayfinding. Minimum standards, signage to be:
*Clearly visible, simple font, font size, contrasting colours, placed in the field of vision
*Washable
*Comprehensive safety signage - fire signage (exits, equipment etc.)
*Restricted areas clearly marked
*Identification signage - each patient space to be allocated a unique number and a whiteboard or perspex sheet for writing the patient’s name
Signs should be posted immediately outside of patient rooms indicating appropriate IPC precautions and required personal protective equipment (PPE).
Signage of a temporary nature can be provided on laminated white A4 sheets attached eye-level. The text should be black sans-serif (for instance Arial) text at least 40point size and centrally positioned on the sheet. Detailed guidance on signage is provided in IUSS Inclusive environments.
=== Safety and security ===
Upon identification of the ACS host site, a team should be convened to conduct a multidisciplinary safety and security analysis. These critical team members need to form the working committee responsible for undertaking the detailed assessment of the existing facility’s security. They should analyse data about the security system’s condition and review existing security concerns or issues that are reasonably likely to become concerns in the near future. The figure below represents a five-zone approach to security, which is a recommended, systematic approach to security.
[[File:Zonal approach to security.png|center|600px|thumb|IUSS Security- Zonal Approach to Security <ref name="IUSS Security">IUSS Hospital design principles - Security [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file]</ref>]]
The security strategy should take into account that whilst clinical services and some logistical and support services will be required 24 hours a day, seven days per week, some support services, logistics services and auxiliary services may only be operational for the minimum periods required to meet demand. These functional elements should be capable of being secured, for example over weekends and at night, as the case may be.
Detailed guidance is available in [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file IUSS Hospital design principles - Security] <ref name="IUSS Security"/>

=== Comfort and dignity ===
Supplemental heating: Patient health and comfort are dependent on, amongst others, maintaining body temperature. The ACS structural technology must be selected to achieve the general indoor environment conditions discussed in a subsequent section for all clinical and occupied areas. As we are moving into South African winter supplemental heating may be required, especially in the evenings, in order to avoid hypothermia. Use of fans, bar, radiator or gas heaters should be prohibited. Unless clinical areas can be maintained above 18 degrees centigrade, patients should each have an infrared heater available, in addition to blankets. Personal/ donated blankets can be considered if they are laundered first and could be destroyed upon discharge.
Mobile screens should be available to provide privacy where necessary (e.g. during consultations or procedures).
<gallery mode = packed heights = 400px>
Bed_Isolator_-Vietnam.png|thumb|Flexible Barrier Isolator<ref>WHO. (2020), Severe Acute Respiratory Infections Treatment Centre. Geneva, Switzerland : WHO- World Health Organization</ref>
ACS Cohort beds.png|ACS Cohort beds.png|thumb|Excel Centre London 04-2020 <ref>Architects' Journal 2020, [https://www.architectsjournal.co.uk/news/nhs-nightingale-bdp-on-the-first-nine-days-converting-the-excel-centre/10046749.article https://www.architectsjournal.co.uk/news]</ref>
</gallery>
Some solutions which address patient privacy and dignity are depicted above.

=== Notes ===
<references/>

== '''Schedule of Accommodation''' ==
Based on clinical needs of the ACS, a schedule of accommodation can be crafted capturing the clinical, clinical, logistical, support and auxiliary services associated with the render of care. When deriving a schedule of accommodation, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital tool can be used. Functions to be accommodated are: 
'''Clinical services''': Triage, rapid assessment of persons entering the facility, to expeditiously identify and render the appropriate service. Admissions and registration. Inpatient accommodation is to be organised according to cohorting principles, discussed above. Testing and diagnostics, including laboratories and x-ray. Safe storage and dispensing of drugs to patients.Offices for clinical administration and clinical planning meeting rooms in the clean zone are needed. 
'''Logistical services:''' Logistical services will entail management of flows of people, goods, services and information to and from the site, as well as within the site. It includes security and communication arrangements. Staff entry, preparations to transition from outside to clinical work environment, including pause areas for relief. Emergency services, visitors. Goods, supplies and storage and waste removal and/ or treatment.
Support services key to the provision of clinical services should be separated so that the risks associated with that particular activity can be managed. 
'''Support services are:'''
*Laboratory services
*Catering
*Laundry
*Environmental cleaning and housekeeping
*CSSD
*Maintenance and cleaning of surrounds, eg. waste areas
*Porters/”runners”, stretchers/wheelchairs
*Mortuary
* Security
Support services can be provided off-site, in which case, safe, secure and efficient transfer and logistical arrangements should be designed. 
'''Auxiliary services:''' Auxiliary services are services which may be provided on or near the ACS site, but which are not directly related to core clinical care. This included overnight accommodation for staff who may not wish to return home to avoid exposing their families, or who need rest between shifts, or for discharged patients awaiting transport home, volunteers who have recovered from SARS-CoV-2.
Limited psychosocial services and allied health services may also be provided on or near ACS for example by approved partners.
Examples of schedules of accommodation for patient and support spaces for a protective isolation ward is available [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedule for COVID-19 Isolation Wards|here]] and mild to severe cases [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedules for COVID-19 Wards for Mild to Severe Cases|here]].

== '''Clinical Services''' ==
=== Triage ===
Confirmed COVID-19 cases and PUIs who are referred from a testing facility or a higher level of care, will enter the facility in a triage area to receive vital screening and initial assessment. They will be registered and admitted to inpatient care. They will be assigned a "ward" or section of the facility - based on disease status and acuity. These are Protective Isolation, the Mild & Moderate ward, or the Critical & Severe wards. Patients should be clustered according to gender. As far as practicable, ablutions for each gender, isolation patients, paediatrics and staff shall be separately provided. Paediatrics patients, if admitted, are to be assigned a dedicated section.
As patients recover or deteriorate, they may be relocated to the appropriate section/ ward.
Once the patient has sufficiently recovered and a negative test result is received they will be appropriately decontaminated and discharged, collecting medication from the dispensary on exit. Patient movement between various sections of the ACS will be restricted as far as possible, with mobile radiology units, in-ward medication dispensing and in-ward food service.

=== Inpatient ACS accommodation ===
Separate spaces for:
*suspected, unconfirmed cases, under observation (PUIs), to be accommodated in isolation facilities (separate rooms, if possible);
*patients with confirmed COVID-19 with mild to moderate disease, not requiring dedicated oxygen therapy;
*patients who require dedicated oxygen therapy;
*patients requiring mechanical ventilation; and
*recovered/ confirmed negative.
==== Protective Isolation Facilities ====
Suspected, unconfirmed cases, under observation – persons under investigation (PUIs) to be accommodated in protective isolation facilities (separate positive-pressure rooms, if possible). PUI are restricted to their rooms. All food and laundry services will be brought to the PUI rooms to reduce interaction and potential contamination. All waste will be collected by facility staff and taken to waste handling areas. Infection prevention and control measures are put in place for the handling of used food utensil and laundry as well as waste collection. PUI areas will have restricted access, including for staff serving other inpatient sections, for confirmed cases.

==== Inpatients accommodation for confirmed COVID-19 ====

Inpatient facilities confirmed positive COVID-19 can be accommodated in large shared ‘wards’ with partitioning between patients. Partitioning between patients is optional. Partitioning is preferable to curtains found in conventional hospitals, as they are more conducive to daily cleaning. If curtains are used, antimicrobial treated fabrics with biocide used to treat the curtains has been tested to international standard EN 14476 and shown to be effective against H1N1 Influenza A Virus (Swine Flu), >99.999% kill rate in 5 minutes and measles morbillivirus, >99.99% kill rate in 5 minutes are preferred. If only separate rooms are available, patient monitoring and surveillance will need to be accommodated. This phase of treatment has a lower area/space requirement compared with PUIs, as cross-infection between patients is less of a concern. Shared ablution facilities are acceptable. It is recommended that, at least, two general accommodation ward areas be provided. 

a) Mild and moderate patients, and 
b) Serious and critical patients. 

The room must have openable windows for natural ventilation if a dedicated positive pressure ventilation system is not available. Ducted ventilation systems shall not be shared between PUI areas and confirmed COVID-19 patient areas. 
[[File:COVID-19 ACS - protective isolation – bed layout.png|thumb|center|800px|ACS - protective isolation – bed layout]]
[[File:COVID-19 ACS – mild-moderate patient bed layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient bed layout]]
[[File:COVID-19 ACS – mild-moderate patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient shared ward layout]]
[[File:COVID-19 ACS – severe-critical patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – severe-critical patient shared ward layout]]

Examples above show bed layout with bed spacing for protective isolation, a mild/moderate patient and a mild/moderate patient shared ward and for a severe/critical patient

=== Patient services ===
Patients in ACS will not generally be ambulatory and will be confined to their room, or cubicle in a bed. In general, domestic beds or hospitality industry (hotel) beds are not suitable for patient care. These should only be used where a hospital-grade bed cannot be sourced, as hospital beds are designed for ease of cleaning and decontamination (for infection prevention and control) and with patient and ergonomics, safety and comfort taken into account (they prevent back injury for nursing staff and can help to prevent bedsores). The higher the specification of bed, the more suitable it is for the higher levels of care. Lockers for patients personal belongings should be provided in the uncontaminated zone (in which case bedside lockers will not be necessary), and it is preferable (where bedside lockers are not provided) for overbed tables to be provided, per bed, if possible. 
The following beds are suitable:
*Repaired and refurbished beds from condemned hospital stocks.
*South African National Standard, SANS 521:2013 Edition 3.5, on Hospital beds and cots ISBN 978-0-626-28830-3.
*Beds listed on the National Treasury (See [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Hospital Bed Specification|specification]]).
The table below details the minimum services required at each patient bed. Details on these services are discussed in a subsequent section of the document.

{| class="wikitable"
|-
! Service/ Capacity!!Triage!!Isolation !!Mild – moderate inpatient!!Severe case wards!!Critical case wards
|-
| Power – 16A 230V Single socket outlet||As needed ||1 per bed||1 per bed||3 per bed||6 per bed
|-
| UPS Power – 16A 230V Single socket outlet ||As needed||1 per bed||1 per bed||1 per bed||2 per bed
|-
| Medical Air<ref group="Note">Mobile units recommended for intermittent use. 3 per 20 beds</ref><ref group="Note">There are some ventilators which have built-in compressors allowing them to function without Medical Air. This is however, not the norm. With Ventilators probably being the most difficult medical device to obtain at present, it would be prudent to rather allow for Medical Air at each bed.</ref> (LP)400kPa||No||Yes||No||Yes||Yes
|-
| Medical O2 -400kPa||Portable/shared||Portable/shared||No||One||Two
|-
| Vacuum-40kPa||No||Portable/shared||Portable/shared||Yes||Yes
|-
| Equipment rail||||||||Yes||Yes
|-
| Upper room UVGI||Optional||Optional||||||Optional
|-
| Examination light||No||No||Yes||Yes||Yes
|-
| Room Ventilation rate||60 L/s per person||10 L/s per person||10 L/s per person||10 L/s per person||12 ACH
|}
'''Notes: '''
<references group="Note" />

Two additional 16A 230V single socket outlets, one two-pin outlet and a worktop should be provided for every 32 beds (or part thereof), for:
*Electrocardiograph (ECG): Could be omitted if monitors have a full 12 lead ECG function.
*Blood gas analyser: Could be omitted if a Lab Services are available.
*Staff cellphone charging.

Example of healthcare technology to be provided for critical care patients is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]. Severe patients may be provided continuous positive airway pressure (CPAP). Emergency trolleys (“crash carts”) are to be provided in patient areas with convenient access to patient beds, out of the passage of corridors and is moved to the patient when needed. 1 crash cart for every 16 patients (or part thereof, with at least one dedicated for PUIs. An example of provisions for a crash cart is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]
==== Patient ablutions ====
[[SARS-CoV-2 is found in faecal matter]], so careful management of patient body fluids is crucial and convenient, practical support for frequent cleaning of ablutions especially shared ablutions is necessary. Dedicated ablutions (toilets and showers) are to be provided for patient use. Toilets and showers should be in separate rooms.
Hand washbasins and or/ hand sanitiser should be provided both inside and outside the toilet room so that patients can wash their hands on the way in and on the way out of the room.
*1 toilet for every 8 persons.
*1 shower for every 8 persons.
*1 disabled ablution for every 8 regular ablutions (or part thereof).
*1 disabled shower for every 8 persons (or part thereof).

Critical and severe patients may be sedated and have a reduced need to access ablutions, ablution facilities proximity and provision can take this factor into account. Showers and wash hand basins should have hot and cold running water. Where possible ablution facilities must have openable windows for natural ventilation, if not possible the bathroom extraction and room ventilation system must be reviewed before admitting patient '''(see [[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|ventilation]]).'''

Portable toilets and showers may be used, provided that suitable hand wash facilities are provided. These will need to be suitably located, preferably in decentralised clusters, so that patients can easily access them without needing to walk very far. Ablutions should be located and designed in such a way as to provide visual and acoustic privacy, dignity and avoid disturbance of other nearby patients when accessing, using or cleaning the ablutions. Separate ablutions are to be provided for PUIs and confirmed patients.

====Makeshift sluice areas ====
In conventional hospital settings, sluice rooms are provided for cleaning and sanitation of soiled equipment, such as bedpans. In a temporary setting, such as an ACS, the establishment of a temporary sluice room may not be practicable, and there may not be facilities for emptying buckets, rinsing equipment etc.. The following is suggested:
Allocate a toilet, hand wash basin, not in splash range and restrict access to it for draining buckets and install a macerator for disposal of disposable bedpans. Electrical, water and waste supply points required as per supplier specification.
==== Dedicated patient treatment areas ====
The following dedicated, private spaces per ward for clinical procedures are recommended:
*Counselling and consulting room (can be shared), as shown in the figure below
[[File:Consulting room example layout.png|400px|thumb|center|Consulting room example layout]]
*Minor procedures room, as per the example provided in the figure below 
[[File:Treatment-minor procedures room example layout.png|400px|thumb|center|Treatment / minor procedures room example layout]]

== '''Logistical Services''' ==
=== Communications ===
Electronic communication should be facilitated in all zones of the ACS by the provision of device charging stations, and wifi.
=== Visitors entry point ===
Visitors are strongly discouraged from entering the ACS.
*In paediatric wards, one parent may be accommodated to visit a patient. In such cases, direct access for the visitor should be provided so that the visitor does not need to pass through the general patient area. Appropriate PPE must be donned before entering the patient area and hand washing/sanitising must be done when exiting the area.
*Non-patients who are accompanying suspected patients to the facility for testing or admission must be accommodated in a well-ventilated, spacious waiting area. Signage in such waiting areas must inform visitors about symptoms, hand hygiene and PPE.
*Hand washing/sanitizing facilities should be provided.

=== Staff areas ===
==== Staff change rooms ====
A minimum of 9m² or 4m² for a single person, increasing by one m² for each additional person is required. The clean (street side) and dirty (contaminated facility side) of the change room should be separated by a step-over barrier.

==== Staff rest areas ====
Staff rest areas within the main facility should be provided with access to kitchenette facilities and staff ablutions.
=== Staff auxiliary services ===
'''Staff on-call:'''Since staff may be required to work long hours or could be required to be on-call, shared, overnight sleeping facilities can be provided for staff on duty, outside the contaminated area, but in close proximity on the patient areas. An example is set out in the diagram below.
[[File:Example of on-call sleeping area for staff.png|center|600px|thumb|Example of overnight sleeping area for staff]]

'''Staff accommodation:''' It is advisable to provide some staff accommodation for off-duty staff who may not have suitable alternatives, for example homes too far away, transport limitations or the requirement not to expose family members to risk. This should be provided in the vicinity of the ACS, but in a physically separated zone. This amenity can be outsourced.

== '''Support Services''' ==
=== Workflow principle ===
[[File:Linen processing cycle.png|none|thumb|Linen processing cycle <ref>IUSS 2014 [https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department]</ref>]]
Progressive workflow from “dirty” (that is contaminated) to “clean” linen is advisable to reduce the risk of exposure to contaminated materials. The workflow diagram below, showing the progression from the dirty linen receiving area, to the cleaning process, to decontamination and drying, and finally sorting and packing, and storage, illustrates this principle.
=== Laboratory ===
[[File:Example of modular laboratory.png|right|thumb|Example of modular laboratory]]
The WHO recommends the following laboratory diagnostic equipment be accommodated:<ref>WHO 2020, [https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items]</ref>.
<nowiki>• Lab screening test kit
• Lab confirmation test kit
• RT-PCR kit
• Extraction kit
• Cartridges for RT-PCR automatic systems
• Swab and Viral transport medium
</nowiki>
Additional accommodation requirements are:
# Reception counter- receiving specimens
# Testing with perspex/ glass screen
# Receiving/Data capture
# Specimen holding
# Toilet - staff
# Blood storage fridge
Can be provided as a modular laboratory unit as shown in the diagram.
=== Pharmacy ===
The purpose of the pharmacy is to provide medicines needed for inpatient treatment and care.
All medical supplies should be stored in a secure, climate-controlled area in close proximity to the patient treatment area. The pharmacy must have dry, lockable, climate-controlled storage of medications. Most pharmaceuticals are labelled with storage temperatures. The pharmacy should have adequate ventilation through an openable window to prevent humidity from building up in the room. Air-conditioning or mechanical ventilation can be provided, if necessary.

Dispensing areas must be well lit. Worktop in space for stock records and administration. Dispensing counters to have perspex or glass screens to serveries. Social distancing implemented at counter, between pharmacists/assistants and between chairs in waiting area.

Can be provided in a mobile unit.

=== Radiology ===
The purpose of radiology services is to provide chest X-Ray services for COVID-19 diagnostics. In general, CT scans, bucky rooms etc. associated with some radiology equipment require specialised infrastructure and therefore is not suitable for ACS. Radiology services can be provided as a mobile floor standing unit, or containerised unit. Alternative technologies such as Lodox and hand-held ultrasound devices are being investigated as potential options and could be confirmed as suitable for use in due course.
=== Laundry services ===
All dirty linen should be handled for bagging or binning inside the patient room/cohort area. The clean linen stock should be stored conveniently close to clinical areas, in a dedicated clean area in the uncontaminated zone. Used linen should be stored in a designated, safe, lockable holding area while awaiting collection. Interim storage areas for soiled linen at the wards is allowable; this may be in dirty linen/ utility room.
Any clean linen for PUI areas should be handled in spaces physically separate from dirty linen of confirmed patient areas. It may be necessary to completely separate PUI and confirmed patient linen streams. Soiled linen and clean linen bags and bins should be dedicated and not mixed.
Full laundry cleaning and drying services may be provided on-site or outsourced. If laundry cleaning and drying services were already rendered on or for the host site before it is repurposed as an ACS, then a suitability and risk assessment should be conducted to ensure that the volumes of laundry generated and infection prevention and control measures are conducive and modifications made as necessary. A new full laundry service may take time and resources to establish, and in general, will not be established at a host site as a temporary solution. Where the site and circumstances advocate for the design of a new laundry or the upgrade of an existing laundry, the IUSS Laundry Services for Hospitals should be applied.
==== Siting and model selection considerations ====
When an existing laundry is being assessed for use or a new one is being planned the following considerations apply:
* Water and power capacity.
* Ease of access to the ACS’s main corridors and internal transport routes.
* The noise factor of the facility and its impact on nearby patient care departments.
For outsourced departments:
* Delivery areas to allow sufficient space to ensure that vehicles can manoeuvre and park easily at the reception and dispatch bays.
* Access to the ACS service roads and public roads.
==== Functional requirements ====
The most basic equipment needed in a laundry includes washing machines, tumble dryers and ironing machines. Equipment requiring steam is not recommended for a temporary facility. The sizing of the laundry, equipment and engineering services can be modified based on the principles provided in the IUSS Laundry and linen.
=== Catering services ===
Kitchenettes, that is, areas for tea, coffee and snacks, mainly for staff, in staff pause areas are discussed elsewhere in this document.
Catering services (for staff and patients) may be provided on- or off-site. If the ACS is to be established with easy access to a suitable, existing, functional kitchen service (e.g. hotel, military or hospital catering) which can meet the additional demand of the ACS, then this should be used. If there is no suitable facility, catering should be outsourced via a suitable off-site supplier. Only in the event that no feasible or suitable, existing facility or local supplier is available, should a new catering service be established at the ACS. Detailed guidance for the sizing, design and layout of catering services can be found in the IUSS Catering Services for Hospitals.
The kitchen (for on-site catering) or preparation area (for off-site catering) should be located with easy access to the point of delivery and storage of food. Adequate food and equipment storage space must be provided.
It is recommended that patient and staff meals, where provided, be supplied in disposable, containers, suitable for incineration, and that these are disposed of as risk waste immediately after use.
Where off-site catering is used, a suitable area for receiving should be provided. Space will be required for sorting meals for distribution and collecting and storing dirty dishes, washing dirty dishes, if necessary, and disposing of left-over food and disposable containers and utensils. The size of the areas required for this will depend on the number of meals delivered.

=== CSSD ===
The primary function of a Central Sterile Supply Department (CSSD) is to provide an efficient, economic, continuous and quality supply of disinfected and sterilised items, when needed, to all patient-care service points in the ACS, and to receive returned contaminated items for cleaning.
CSSD with limited sterilisation capacity (autoclave) but sufficient disinfection capacity (instrument washing). The layout requires a designated clean and dirty areas with a hard barrier between to avoid cross-over of staff and equipment. Work is unidirectional - flows from dirty – to clean - to sterile areas.
This yields three distinct zones:
1. Receiving and cleaning with pass-through windows
# Dirty receiving with Perspex or glass partitioning
# Dirty utility
# Decontamination and cleaning/wash area with throughput instrument washing
# Trolley wash/Park – external
2. Inspection, assembly and packaging with pass-through windows
# A tabletop autoclave
# Instrument washer
# Clean Packing area
3. Sterile processing, storage and distribution. (Separate issuing area from receiving area) with pass-through windows
# Store -linen and consumables
# Sterile pack store
# Issue - Collection hatch with Perspex or glass partitioning
Must also have a secure, separate receiving area for consumables receiving and storage.
An example of a CSSD unit is shown in Figure 21.T

[[File:An example of a small CSSD facility.png|600px|thumb|none|An example of a small CSSD facility<ref>IUSS 2014, https://www.iussonline.co.za/norms-standards/support-services/24-central-sterile-service-department</ref>]]

To be understood: Quality of services, eg. water (including a source of distilled or ionised water for rinsing of bronchoscopes) and electricity, quality of management, if equipment is appropriate for needs and fit for purpose, what is required of the equipment in the near and far future (relocation?), compliance with S.A. National Standards for CSSD, compatibility of equipment and devices, correct chemicals, maintenance of equipment, training of operators. Although the use of disposable breathing circuits and accessories (masks) should be encouraged, the capacity to disinfect these items if disposable is not available must be considered.

The CSSD must be sized to serve the ACS. Considerations are workload and space requirements. CFSA has extensive [https://www.fidssa.co.za/Content/Images/CFSA_SOP_2018.pdf standard operating procedures] for CSSD.

Workload: Number and type of procedures, number of procedure rooms, eg for bronchoscopy, operating hours, available inventory, volume of work and peak times, degree of mechanization, eg. manual or automated instrument washing, amount of product to be stored – chemicals, barrier wrap, chemical indicators, etc., storage and distribution records, quality records – eg. equipment checks, disposal needs.

Space requirements: Space for separation of clean and dirty, allow for unidirectional movement, allow space to manoeuvre trolleys (queue, pack/unload), reduce lifting and carrying heavy items, reduce awkward movements, allow for tidy work areas. Insufficient space will compromise sterility!

Preference should be given to construction materials and finishes which are suitable for frequent cleaning and tolerant to chemicals, including bleach (sodium hypochlorite). Impermeable flooring, non-slip and smooth washable walls are needed. Joints at walls and floors and coving at wall edge, and exposed drains should be avoided. Worktops should be sealed and should be ergonomically suitable.

Ceiling heights below 2.8m may be vulnerable to damage from humidity Where steam and moisture are generated. Noise – insulation of washer-disinfector and steriliser in technical walls will reduce noise. Lighting: Natural light if possible – windows sealed. High luminance if artificial lighting. Open, slatted shelves for sterile store area. Sinks for manual washing: At least two basins, deep (25cm at least) basins, 91 cm from floor, wide and long enough for the biggest instrument tray or container, water ports for flushing of lumens.

The CSSD space allocation and layout should be determine based on what procedures and which medical devices will be required. A typical [[equipment list is provided here]].

=== Maintenance and cleaning ===
Maintenance and cleaning services must be accommodated with offices located away from clinical areas.

=== Mortuary services ===
The National Department of Health has issued guidance on handling of dead bodies and infectious remains<ref>National Department of Health South Africa, 2020 [https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf]</ref>, which should be applied to ACS. While some guidelines have recommend that bodies of persons who have died from COVID-19 should only be held for a very brief period prior to cremation or treatment for burial<ref>Zhejiang University, 2020 [http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm]</ref>, the WHO holds the view (at the time of writing) that there is no evidence of persons becoming infected from exposure to bodies during normal ceremonial and burial activities. However, appropriate PPE should be used when handling such bodies with additional airborne precautions to be taken during autopsies<ref>WHO, 24 March 2020 [https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf]</ref>.

Either body cabinets or a refrigerated room could be used for body storage.
==== Location and layout of mortuary service ====
It is likely that not all alternative care sites will have a mortuary. Those without a mortuary must have a holding room that is located away from general access areas. This holding room must be suitably sized and conditioned. A recommended room size is 3.5 m x 3.4 m<ref>IUSS Adult Inpatient Services, 2014, [https://www.iussonline.co.za/docman/document/clinical-services/65-adult-inpatent-services-gazetted/file]</ref>
A mortuary should be located so that it is easily accessible to mortuary staff and related service providers and visitors without presenting either aesthetic, emotional or ethical problems for unrelated staff, patients or visitors. It should be separate from the general facility, allowing access for the family to view a body without passing through any potentially contaminated area of the facility. The visitors’ entrance should be external and completely separate from other access points.
Appropriate routes should be designated so that bodies are not moved through public-access areas.
==== Sizing of mortuary ====
The layout and size of a mortuary are largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.
==== Services ====
The following services are required in a mortuary:
* Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.
* Sluicing facilities are to be provided in both the body-preparation and autopsy areas if they are not a common area.
* Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush-fitted stainless steel grids.
* No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.
* The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.
* Anti-backflow devices should be fitted to the water-supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.
* Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.
==== Finishes ====
Wall and floor finishes should be impervious to liquids and easily cleanable.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Environmental Controls''' ==

=== General Indoor Environment Conditions ===

Existing environmental control systems should be modified to suit requirements in the facility. The following issues should be considered:
* Systems should be set to maximise the introduction of fresh air and maintain the pressure regime (see ventilation).
* The following internal temperature range should be maintained 19 - 24oC.
* Cooling systems should be able to cater for projected internal heat gains from people, lighting and equipment. Indicative heat gains in treatment areas are 8W/m2 from people, 15W/m2 from lighting and 3 W/m2 equipment and in critical care areas 16W/m2 from people, 15W/m2 from lighting and 60W/m2 equipment.
*As heat gain can vary widely between items of equipment, heat gain and utilisation rates for equipment should be obtained from the manufacturer to establish this more accurately.

=== Solid waste from ACS ===
According to the National Department of Health COVID-19 Environmental Health Guidelines
“All solid waste from the facility should be regarded as potentially infectious material and therefore appropriate precautions should be taken". The management of healthcare risk waste (HCRW) should follow the correct identification segregation, storage and disposal processes as indicated in SANS 10248-1.

* HCRW is segregated at the point of generation and shall be containerized to minimize the risk of contamination.
* Waste generated from patients in isolation or quarantine in a designated facility health facility is treated as health care risk waste (HCRW) as per SANS 10248-1-2008.
* The HCRW is properly packaged in a sealed, leak and puncture-proof containers/ boxes.
* The HCRW is labelled with the biohazard symbol/ sign and marked “Corona virus or COVID-19”.
* The HCRW is stored separately from other waste generated.
* The collection, transportation, treatment and disposal is provided by only an appointed/ appropriate contractor/ service provider, however, ensure that waste is safely stored until the health care waste management company can pick it up and that the company knows and acknowledges that waste was generated by suspected or confirmed COVID-19.
* The waste management company collecting must ensure that and treated and disposal is conducted at license waste treatment/ disposal facilities .
* All personnel or staff in contact with patients must be geared with appreciate personal protective equipment (PPE’s) at all times to prevent exposure or risk to health.
* Monitoring should be done at such facilities.
* All, bags, bins and boxes must be adequately sealed, as not to leak any fluids, and must be wiped down with 0.05% chlorine solution

Measures developed should consider the following.
* Develop a waste management plan following national guidelines and best practice standards for the disposal of medical waste (WHO, 2020).
* Establish procedures with medical waste service providers to regularly pick up the waste and dispose of this safely.
* Provision should be made for 5kg of solid waste per bed per day and this should be monitored and supplemented where it appears this may be inadequate.
* Ensure that access to waste is secure and controlled, for instance, by using lockable waste 1000l containers kept in a location that can only be accessed by health facility and nominated service delivery staff.
* Vermin control programs must be implemented throughout the site with HCRW collection points prioritised
* Provision for safe cleaning and disinfection of reusable containers should be provided. Cardboard, single-use HCRW boxes are removed from site and incinerated.
* Waste must not be allowed to accumulate or be stored inappropriate or unsecured containers.

== '''Engineering Services''' ==
Engineering services include patient services, ventilation, electrical power, water, medical gases, oxygen, compressed air, vacuum, lighting, and fire safety that support the needs of the patients and medical staff under normal and emergency situations. Good practice standards are provided in:
* IUSS Building Engineering Services<ref name = "IUSSBES">IUSS 2017, [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file]</ref>
* NHS Nightingale Instruction Manual<ref name="BDP2020">BDP 2020, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf]</ref>.
The guidance below draws on these and other manuals and standards. 

=== Building ventilation ===
==== Mechanical ventilation ====
While SARS-CoV-2 RNA has been detected in aerosol form, in experimental mechanical aerosolization studies, it is primarily spread through droplet and contact spread and the potential for airborne transmission is thought to be low.
However, the following advice is provided by ASHRAE regarding HVAC systems in general spaces (not specific to healthcare):
Effective high levels of ventilation must be achieved in the facility. Existing ventilation systems should be tailored to suit internal layouts and requirements and the following measures should be taken.
* Mechanical systems should be set to maximise fresh air supply to the facility. There should be no recirculated air without HEPA filtration or other validated decontamination processes.
* A pressure regime should be established, as shown in figure 2, to 'push' air from clean areas, to dirty areas and then out of the building.
* A clean air supply of over 10 L/s per person should be targeted for odour control.
* Fresh air supply shall not be located near patient beds to avoid drafts in winter.
* Extraction points can be located near patient beds in isolation wards or at a high level in long-stay wards. Short-circuiting of air between high-level supply and extraction is a performance risk in winter.
* Noise from ventilation systems and fans shall be below 45 dBA
* Protected lobbies, internal partitions, door arrangements, fans and extracts should be used to maintain the pressure regime and airflow as indicated in the diagram below.
 

[[File:Ventilation in temporary facilities.png|600px|thumb|none|Ventilation in temporary facilities<ref name="BDP2020"/>]]

==== Natural ventilation ====
The airflow direction between naturally ventilated zones may fluctuate according to the wind direction. This is not of concern within and between contaminated zones where occupants are either protected with mandatory PPE or confirmed to be infected with disease strains similar enough so as not be able to reinfect others. Where levels of occupant susceptibility to an airborne disease is significantly different, the less susceptible areas (such as PUI areas and uncontaminated areas) shall be protected from the naturally ventilated and contaminated areas by mechanical ventilation systems with a capacity sufficient to overcome the expected natural ventilation pressure fluctuations (typically 5-15Pa). Where such mechanical ventilation systems are not feasible or expected wind pressure is too great, zone adjacently must be avoided.

===Ultraviolet germicidal Irradiation===
The application of Ultraviolet Germicidal Irradiation (UVGI) for room air disinfection is well understood and is proven to be effective in the disinfection of microorganisms including M. tuberculosis (TB) in air. UVGI should, therefore, be considered as a valid element in indoor airborne infection control strategy for high volume settings. Studies have demonstrated the importance of good vertical air mixing in the room, and the safety of UVGI application. In areas where UVGI is indicated, the design and development of UVGI systems should be in accordance with the [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]<ref>van Reenen et al,2019 [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]</ref>

=== Electrical power ===
Sufficient and reliable power must be available at the facility for envisaged medical equipment, medical gases, lighting and building ventilation equipment. Power installations for the temporary facility can be divided into three zones as indicated below. These are existing services, the temporary service zone and services in each bay.
The following should be considered by competent engineering professionals.

=== Existing services ===
*Capacity: Evaluate whether sufficient power to accommodate envisaged medical equipment, additional lighting and heating, building ventilation and air conditioning can be provided. If existing capacity is insufficient, investigate if it is possible to route additional power from additional locations/transformers around the site or from adjacent sites.
* Safety: The existing electrical distribution network must be able to supply the required equipment load. If this is insufficient/appears unreliable, identify how this can be supported.
* Resilience: Evaluate back-up power and a UPS capacity against essential services demand. If existing capacity is not sufficient, source and establish temporary service capacity.

=== Temporary service zones ===
*Identify locations for temporary service zones where equipment can be located.
*Ensure that equipment and maintenance access is safe and easy.
*Ensure that all distribution boards, circuit breakers and cables are clearly labelled.
=== Services in each bay ===
*Provide pre-wired power strips/trunking as per bay requirements.
*Check that these include sufficient electrical outlets and service points for envisaged equipment.
*Ensure that trunking will carry required equipment loadings. The IUSS Building Engineering Services Guide can be used to check requirements<ref name = "IUSSBES"/>.

[[File:Layout_of_power_in_a_temporary_installation.png|600px|thumb|none|Layout of power in a temporary installation <ref name="BDP2020"/>]]
----

=== Water ===
Water points are needed for handwashing, showers and cleaning. The following issues need to be taken into account.
==== Supply ====
Onsite cold water storage, dedicated to the domestic water requirements of the facility, should be provided. A minimum usable volume of 500 litres per bed should be available.
Hot water storage and consumption should be confirmed by an engineer, as follows:
*Storage 25 L per bed.
*Consumption 180 L/bed.day W/O laundry; 250L /bed. day W laundry.

==== Handwashing ====
See infection control for clinical wash-hand basins
==== Showers ====
Showers for staff coming off shift should be available. Staff flow routes exiting contaminated treatment areas should pass through gowning and shower areas.
----

=== Medical gases, oxygen and vacuum (suction) ===
Medical gases, oxygen and vacuum services will be required in the facility. Mobile gas supply requires piping between supply and patient and clutter floor space. Preferably used fixed installations for patient rooms/cubicles, if possible.

System capacity and point of use pressures and consumption rates are to be ensured at all points. WHO provides technical guidance on [https://www.who.int/publications-detail/oxygen-sources-and-distribution-for-covid-19-treatment-centres oxygen sources and distribution]. 
[[File:Medical gas service layout.png|6oopx|thumb|Medical gas service layout<ref name="BDP2020"/>]]
The following points should also be taken into account.
* For centrally supplied medical gas and vacuum services, system resilience and availability must be ensured.
* Compressors, tanks, accumulators, VIEs, headers and controllers must be secured from uncontrolled access.
* Where possible, gas piping should be reticulated below floors or in ceilings to ensure protection from tampering, damage and ease of access.
* Where reticulation is within open areas, high-level reticulation with point-of-use droppers is advised. Low-level reticulation within rooms is to be avoided.
* Flexible piping can be used, ensuring it does not present a contamination or fire risk and should comply with local regulations. Special care should be taken with flexible O2 piping, keeping it to a minimum.
* Vacuum piping may be contaminated, where point-of-use filtration and collection systems fail. Precautions should be taken when demounting or disconnecting temporary vacuum lines.
* Ensure that oxygen pipelines are designed to provide sufficient flow to all oxygen points in the facility. In terms of utilities, oxygen and medical air would be required. A temporary vacuum point can be provided by mobile medical vacuum units distributed throughout the unit.
* Mobile medical air supplies should be considered where reaching piped specifications are not feasible. Where flexible hoses are used for oxygen and medical air special precautions need to be taken. Flexible oxygen piping must be chemically safe for O2 use. Where perishable flexible piping is used for medical air, terminal filtration at the point-of-use may be required at point-of-use. Especially for long-term use.
* Electrical and gas services can be reticulated against pipe racks or boards fixed to the bed-heads for head to head bed arrangements.
* Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.
* Gas service outlets to be labelled and colour-coded with 3mm lettering.
* SANS 7396-1 should be used to specify the requirements from design to commissioning of medical gas and vacuum systems.
* Medical gas and vacuum pipelines shall be marked per SANS 7396-1 and ISO 5359, as applicable.
* Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.
* SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.
* Plain-ended copper tubing for low-pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.
* Laboratory gas taps and valves shall be marked as described in SANS 10140-4.

=== Lighting ===
Existing lighting systems may need to be modified to suit the clinical requirements in the facility. High bay lighting presents inadequate colour rendering quality for the accurate detection or easy diagnosis of certain clinical conditions. This needs to be evaluated in the selection of supplementary lighting systems.
*Lighting levels should be provided in line with the indoor lighting levels recommended in the Table 6 of IUSS Building Engineering Services .
*Mobile task lighting systems may be adopted in the serious and critical stay wards to supplement incorrect lighting quality.
*Emergency lighting and illuminated emergency egress signage should be linked to the back-up power system.
*External security lighting in external parking areas and spaces around the building should be enhanced to ensure the security of medical staff who need to change shifts at night.

=== Fire safety ===
A functional fire alarm system should be available to support the patient care setting. Fire is a very real threat due to the possibility of an oxygen-enriched atmosphere developing so ventilation is crucial.
The use of temporary facilities for medical care should note the following fire risks (NHS, 2020):
*Patients may have a very high dependency.
*Areas are not specifically designed for patients and do not meet guidance on fire compartmentation and progressive horizontal evacuation.
*Large numbers of patients supplied with oxygen up to 10 litres per minute.
*Possibility of oxygen concentrations exceeding those generally found in the atmosphere- less risk if effective ventilation or large volume i.e. high ceilings.
* Possibility of storage, in excess of 40 litres, of alcohol-based chemicals (such as hand-rub), necessitating a flammables cabinet on site.
*Staff who may not normally work together .
*Staff who may not be familiar with the area.
*Staff not trained in fire safety, progressive horizontal evacuation or oxygen isolation for the specific area.
These factors should be taken into account in fire risk assessments which should then address significant findings in an action plan. Fire assessments should be undertaken by a qualified person and shared with operations and building management staff within the facility. Measures developed should include:
*An automatic fire detection system
*An emergency egress plans are prepared that include patients who have a very high dependency.
*Signage, notices and lighting are installed and are working effectively.
*Management processes are in place to minimise the risk of fire from ignition sources, fuels and oxygen.
*Staff are trained and a fire safety guide sheet for staff is developed and issued.
*Emergency egress routes are kept clear.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Additional Resources''' ==
=== [[Directory of Service Providers|A Directory of Service Providers can be viewed here]] ===

=='''References'''==
<references />

[[Category:COVID-19| ]]
[[Category:Alternate Care Sites|Alternate Care Sites]]

----
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19|(Return to Top)]] 
----

Infrastructure Guidance for COVID-19/Alternate Care Sites

2020-05-08T08:45:57Z

Peta: /* General Indoor Environment Conditions */

[[Infrastructure Guidance for COVID-19|Return to Infrastructure Guidance for COVID-19]] 

== '''Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19'''==

This guidance work was initiated under the project titled: 
''Reducing Nosocomial and Community-Acquired Tuberculosis by Strengthening the Capacity of the South African Department of Health to Improve Implementation of Infection Control and Waste Management at All Levels of the Health System Under the President's Emergency Plan for AIDS Relief (PEPFAR)'' 

== '''Introduction''' ==
=== Purpose and approach ===
The global pandemic of COVID-19 caused by the coronavirus, SARS-CoV-2 is likely to result in a surge in need for medical care for Severe Acute Respiratory Syndrome (SARS) in South Africa. Considering the course of the pandemic in other countries, it is anticipated that South African hospitals will not have sufficient capacity to cope with the surge of persons requiring medical attention and that surge capacity via alternate care sites (ACS) will need to be established.
Surge capacity, contemplated here is not the frequent emergency department overcrowding experienced by healthcare facilities (e.g. Friday/Saturday night emergencies) or local casualty emergency that might overcrowd nearby facilities and have little to no impact on the overall healthcare delivery system. It is when a catastrophic event occurs and the affected population seek medical care from existing local healthcare facilities, causing healthcare infrastructure to become exhausted due to excess in demand. During a healthcare surge, the standard of care will shift from focusing on patient-based outcomes to population-based outcomes, and providers should anticipate “a shift to providing care and allocating scarce equipment, supplies and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals.”<ref>[https://asprtracie.hhs.gov/technical-resources/resource/491/altered-standards-of-care-in-mass-casualty-events Health Systems Research Inc., 2005]</ref> 

Surge capacity can be temporarily established in non-traditional environments, such as hotels, exhibition halls, community halls, and as field hospitals, on open spaces. 

In the context of this document, a quarantine site is a facility for patients who do not require continuous professional medical care, while an ACS is defined as a temporary facility that can provide continuous medical care for SARS. This document provides principles and considerations, high-level guidance for minimum requirements and examples for ACS. 

While an extensive set of health facility guidelines does exist<ref>[https://www.iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-servi IUSS Building Engineering Services (2017)]</ref>, these are applicable for conventional facilities and thus include services and guidelines that are not necessarily relevant to the treatment of a novel, highly infectious pathogen, with pandemic effects. Moreover, these do not provide well for the rapid and temporary establishment of facilities. 

In order to formulate high-level guidance, [[as invited by Business for South Africa]], the team reached out to professional industry bodies for inputs, in particular the South African Institute for Architects (SAIA), The Gauteng Institute for Architects (GiFA) [https://www.gifa.org.za/ Gauteng Institute for Architecture] and the [http://www.safhe.co.za/ South African Federation of Hospital Engineering (SAFHE)], by inviting input via a 36-hour research charrette. Relevant historical and contemporary literature was consulted, precedents identified and critically reviewed. An interaction with the team at Wuhan responsible for makeshift hospitals and emergency infectious diseases hospitals, Central-South Architectural Design Institute, was arranged with assistance of the Chinese Embassy. Material from the [[Infrastructure Unit System Support|Infrastructure Unit System Support (IUSS)]], international literature and guidance and input gathered from the broader architectural, engineering and healthcare professional communities was synthesised and moderated by the CSIR team. The draft was reviewed by an expert review panel. 
=== Acknowledgement of contribution ===
The contributions to the initial version of this were gratefully received. [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Acknowledgements|A list of these contributors can be viewed here.]]. 
New contributions are eagerly encouraged along with debate and discussion on the [[Talk:Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites|'''discussion forum.''']] tab above.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Scope and Assumptions''' ==
ACSs as discussed in this document are dedicated, temporary facilities for triage, testing, diagnosis, further referral and treatment of persons:
*suspected of having contracted SARS-CoV-2, (persons under investigation (PUIs)), who are symptomatic and/or are awaiting results,
*or are confirmed to be infected.
ACS will accommodate a variety of clinical, logistical, support and auxiliary services associated with the render of care. ACS will currently not be licensed to provide healthcare services. Since the ACS will operate in a non-healthcare facility, it cannot fully replace a hospital setting and its prime objective is to manage the patient load until the local healthcare system can meet demands. 

=== Exclusions ===
Quarantine facilities are accommodation facilities where a member of the community can remain for the duration of their isolation period. This is typically temporary housing for a cohort of people who do not need intensive medical attention but who cannot stay at home. Patients can take care of themselves and need limited monitoring by medical staff. Quarantine: Containing presumptive-case patients from each other and the general population.
Quarantine facilities – that is for asymptomatic persons who are in the community in self- or imposed isolation, but not displaying symptoms, or who are symptomatic, but are able to safely recover without clinical intervention and do not need continuous medical observation are not considered in this document.

=== Service regime ===
The following assumptions are made with respect to services under consideration.
* Temporary - limited to the part of the pandemic when the “conventional” hospital platform cannot meet demand. To be dismantled, thereafter.
* Uncomplicated, dedicated COVID-19 care is to be prioritised for ACS.
* Patients with comorbidities, paediatrics will be prioritised for conventional facilities, and only accommodated in ACS as a matter of last resort.
* 24 hour, 7 days a week operations. 

=== Assumed mechanism of transmission ===
Transmission of SARS-CoV-2 is understood to be from person to person firstly by [https://en.wikipedia.org/wiki/Transmission_(medicine)#Droplet_infection droplet] transmission, then by the [https://en.wikipedia.org/wiki/Transmission_(medicine)#Direct_contact contact] route and finally via airborne [https://en.wikipedia.org/wiki/Transmission_(medicine)#Airborne_airborne transmission] during or following mechanical aerosolisation. Water transmission risks are minor, occurring in special [https://en.wikipedia.org/wiki/Transmission_(medicine)#Fecal%E2%80%93oral Fecal-oral] circumstances. Reclassification of transmission mechanisms may nullify some of the approaches presented in this guidance. 

=== A call for strategic coordination ===
This document focusses on infrastructure requirements. These provisions are meaningless without staffing, equipping and resourcing. Whilst staffing, equipping and resourcing are not the focus of this document, these are likely to emerge as key constraining features. Resource constraints are likely to become acute during this pandemic. Doctors and nurses are already in critical short supply in South Africa and internationally, and are themselves susceptible to COVID-19 infection. Equipment and consumables are in short supply with heightened global demand, reduced manufacturing capacity and limits in trade flows. This necessitates strategic coordination, proactive planning, options appraisal and prioritisation. 

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Status Quo''' ==
=== Rationale and transmission status ===
According to the [https://en.wikipedia.org/wiki/World_Health_Organization World Health Organisation] (WHO), based on the largest cohort of COVID-19 patients, about 40% of patients with COVID-19 may have mild disease, where treatment is mostly symptomatic and does not require inpatient care. About 40% of patients have moderate disease that may require inpatient care; 15% of patients will have severe disease that requires oxygen therapy or other inpatient interventions, and about 5% have critical disease that requires the patient to receive mechanical ventilation. However, the evolution of the outbreak in some countries has shown a higher proportion of severe and critical cases and the need to rapidly increase surge capacity to prevent rapid exhaustion of biomedical supplies and staff. In some countries, doubling rates of cases every three days has been observed<ref>WHO-2019-nCoV-HCF_operations-2020, [https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf]</ref> 

South Africa has a high burden of disease, with a high prevalence of [https://en.wikipedia.org/wiki/HIV/AIDS_in_South_Africa HIV and TB]. Although evidence is yet to emerge of the effect of SARS-CoV-2 on a population with these pre-existing conditions, there is reason to proceed with caution<ref>The Conversation 2020, https://theconversation.com/tb-hiv-and-COVID-19-urgent-questions-as-three-epidemics-collide-134554</ref>. There is a potential direct and indirect benefit of ACS to people living with HIV and TB, as well as to general public health and the health system preservation. 

With the travel lockdown in place, and continued transmission, it appears that South Africa is on the cusp between cluster transmission and community transmission according to WHO’s classification, shown in the [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites#Key_clinical_and_infection_control_activities_for_different_transmission_scenarios_.5B3.5D|table below]], indicating that preparation should include temporary hospital facilities and mass critical care.

==== Key clinical and infection control activities for different transmission scenarios <ref>WHO 2020, [https://apps.who.int/iris/handle/10665/331492 https://apps.who.int/iris/handle/10665/331492]</ref> ====
{| class="wikitable"
|-
! !! '''No Case''' !! '''Sporadic Case''' !! '''Clusters of Cases''' !! '''Community Transmission'''
|-
| Faculty Space, Including for Transmission|| Usual Space. Enhanced Screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards). || More patient care areas re-purposed for COVID-19 within the health system, especially for severe cases || Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Staff|| Usual space. Enhanced screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards)||More patient care areas repurposed for COVID-19 within the health system, especially for severe cases||Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Supplies||
*On-hand supplies. Equip wards for COVID-19 treatment.
*Identify essential equipment and supplies, including oxygen.
*Prepare expanded local supply chain
||
*Expanded inventory of supplies with detailed protocols for use.
*Activate expanded local supply chain.
*Prepare national supply chain.
||
*Conservation, adaptation, selected re-use when safe.
*Activate contingency planning and procurement for essential equipment and supplies.
*National supply chain.
*Prepare expanded supply chain at the global level
||
*Activate contingency planning should critical equipment be in short supply.
*Determine allocation of lifesaving resources for HCWs and patients.
*Activate expanded global supply chain
|-
| Standard of Care|| Usual care with enhanced awareness and recognition of immediate needs for first COVID-19 patients|| Usual care and treatment for all patients, including those with COVID-19||Identify context-relevant core services. Shift service delivery platforms. Consider reduction in elective patient encounters, including elective surgical procedures.|| Mass critical care (e.g. open ICU for cohorted patients).
|-
| Care areas expansion|| No requirements for expansion|| Designate 10 beds per suspected COVID-19 case|| Expand COVID-19 patient care areas by a factor of 35 ||Expand COVID-19 patient care areas by a factor of 58
|}

=== Quantification of need ===
At this time there are various parallel initiatives aimed at forecasting the South African epidemic, quantifying the projected need for facilities, and a shortfall in existing capacity. At this time, there is no consensus on this. This section will be updated as further data becomes available.
ACS will prioritise mild to moderately affected COVID-19 patients where basic, targeted medical care will be provided. Should patients’ needs evolve, requiring escalation of care, then the transfer of patients from ACS sites to conventional sites of care will be needed as a matter of course, bringing with it logistical challenges and risks. In the event that the conventional hospital platform is unable to cope, ACS will have pressure to provide care for severe and critical patients, and finally for patients with comorbidity and special requirements, such as paediatrics, persons living with HIV (PLHIV), TB patients and pregnant women. The following pragmatic approach, aligned with the WHO recommended strategic approach, is suggested.
*ACS should preferably be identified with space for expansion.
*The set-up should be done so that levels of care can be upgraded to higher levels of uncomplicated care.
*A secondary upgrade for more diverse package of care may become necessary.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Strategic Approach''' ==
According to WHO, clinical interventions must be put into place immediately and then scaled up according to the epidemiologic profile.
[[File:COVID-19 Resource allocation.png|none|thumb|600px|right|WHO Strategic approach to clinical care]] 
Under this declared state of disaster, the clinical care strategy which cannot be accommodated within existing facilities, can, on a temporary basis be hosted in ACS:
*Within and around existing healthcare facilities, via reconfiguration and/or augmentation.
*In existing non-healthcare buildings suitable for repurposing, such as universities, hotels and conference centres, warehouses, gyms, hostels etc.
*On open fields, including paved parking areas with rapidly constructed, dismountable structures, such as modular tented structures or using rapid modular construction techniques. 

ACS will provide isolation, general (non-acute) care for patients with mild to moderate symptoms and as required, acute care for patients with severe symptoms. Containing confirmed-case patients from general population. Confirmed-case patients can be housed together en masse, while presumptive-case patients must be individually quarantined.
As shown in the WHO Strategic approach to clinical care, the WHO recommends a range of services to meet patient need (''Citation needed''). General (non-acute) care ACS model is designed for minimal acuity patients requiring minimal activities of daily living support (e.g. COVID-positive with minimal symptoms or require <2L of oxygen). Acute care ACS model is designed for higher acuity patients requiring closer monitoring or respiratory support (e.g. COVID-positive with pneumonia or respiratory distress requiring ventilator support). Paediatric patients are to be accommodated in separate wards, where strictly controlled visitation may be allowed. 
As a preliminary estimate, the following ratios of service is proposed:
[[File:COVID Ratios of Service.png|none|thumb|600px|center|COVID Ratios of Service]]

{| class="wikitable"
|-
! '''Case severity, risk factors<ref group="Notes"> Test suspect COVID-19 cases according to diagnostic strategy</ref><ref group="Note"> Known risk factors for severe COVID-19: age over 60 years, hypertension, diabetes, cardiovascular disease, chronic respiratory disease, immunocompromising conditions.</ref>''' !! '''Recommendations'''
|-
|Mild || Patient should be instructed to self-isolate and contact COVID-19 information line for advice on testing
and referral.
|-
|Moderate, with no risk factors ||Test suspected COVID-19 cases according to diagnostic strategy. Isolation/ cohorting in:
* Health facilities, if resources allow;
* Community facilities (e.g. stadiums, gymnasiums, hotels) with access to rapid health advice
(i.e. adjacent COVID-19 designated health post/EMT-type 1, telemedicine)
*Self-isolation at home according to National guidance
|-
| Moderate, with risk factors || Patient should be instructed to self-isolate and call COVID-19 hotline for emergency referral as soon as possible
|-
|Severe || Hospitalization for isolation (or cohorting) and inpatient treatment.
|-
|Critical|| Hospitalization for isolation (or cohorting) and inpatient treatment.
|}

=== Notes and References: ===

<references group = "Note" />
<references />

=== Typology dictates & case studies ===

[[File:NHS Nightingale Hospital London.png|thumb|NHS Nightingale Hospital London <ref name="NHS Nightingale Hospital London">Coronavirus: Building NHS Nightingale Hospital London, 2020 [https://www.bbc.com/news/in-pictures-52092253 https://www.bbc.com/news]</ref>, ]]
To meet the requirements set out in this guidance, prospective “host” sites should be carefully evaluated. The type of “host” site selected will strongly influence or dictate the choice of ACS service model.

No site is likely to meet all requirements and recommendations set out in this document. Adaptations and compromises will be necessary. Services should be provided on site where it is pragmatic to do so, for example where similar services are provided. Outsourcing can also be practical/feasible for some services, such as laboratory services, catering and laundry, provided suitable logistical arrangements can be made.

Some typological responses and service models are set out in precedent examples, shown below. The examples demonstrate that a variety of host settings are workable, provided that the appropriate utility can be contrived.

=== Pragmatic approach ===
Other than in metropolitan areas, co-location of ACS on the premises of, or adjacent to existing healthcare facilities will often be preferable because this is where intensivists and specialist clinical staffing will be available, and support services may be well established. Nevertheless, augmenting capacity at existing facilities should take into account current workloads and capacity to ensure that the COVID-19 surge disrupts normal service provision as little as possible, including continuity of care for patients with chronic conditions and TB and HIV patients. 

*'''[[Infrastructure Guidance for COVID-19/Alternate Care Sites/Case Studies|SARS ACS Precedents and Case Studies can be found here]] '''

=== Notes and References ===
<references />

== '''ACS Infrastructure Planning''' ==

=== Establishing a team ===
A planning team should be formalised to establish the minimum planning and operational requirements for the ACS and to liaise with the local community. The team should include individuals with expertise in the following areas (ideally with knowledge of healthcare delivery under emergency conditions):
*Disaster response / emergency management coordination,
*Clinical care and staffing,
*Infection Prevention and Control practitioners must be involved in all stages of planning, commissioning, in-use, and decommissioning of the facility
*Facility set-up, operations and management,
*Security,
*Transport (patient, staff),
*Engineering and project management,
*Procurement and coordination of supplies, equipment and pharmaceuticals, and
*Community liaison to ensure that concerns of the adjacent population on understood an addressed.
It is important to ensure compliance with health, safety and building regulations, by ensuring the involvement of relevant local authorities. Stakeholder engagement should be formally documented. Concerns and grievances should be systematically addressed.

=== Structural integrity and operational responsibility ===

'''Structural modifications:''' ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered. 

'''Competent person:''' All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed. 

'''Asset responsibility:''' Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented. 

'''Integrity and responsibility'''

'''Structural modifications''': ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered.

'''Competent person''': All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed.

'''Asset responsibility''': Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented.

'''Decommissioning''': Decommissioning of the facility shall be assigned to the competent person discussed above. All residual structures upon decommissioning shall comply with the National Building Regulations. Upon decommissioning, removal of equipment shall be the responsibility of the owner. An infection prevention and control practitioner should be engaged in the decommissioning phase to oversee terminal cleaning and disinfection of equipment and premises.

'''Closure''': Once all patients can be safely discharged or transported back to existing facilities for continued care and there are no ongoing healthcare surge capacity needs, the ACS can be closed. Shut down of an ACS will require decommissioning, identification of new homes or storage for equipment, and termination of ongoing contracts or arrangements. Shut down should be expedited so that the facility can quickly be returned to the control of the existing owners and returned to its usual function.

Action checklist items for ACS closure should include, but not be limited to, the following:
*conduct a site walk-through with the facility owner when shutdown activities are completed to ensure that terminal cleaning and disinfection of supplies and premises, removal of equipment and supplies, and other surge closure activities have been completed to the owner’s satisfaction.
*perform medical records storage procedures.

== '''Site Selection''' ==
When selecting a site, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital can be utilised to determine whether the site is suitable for a 100, 1000 or 2000 bed facility, as required. The following indicative minimum site sizes are needed:
*100 Bed ACS/ hospital conversion, requires ± 4 300 m2
*1000 Bed ACS/ hospital conversion, requires ± 17 600 m2
Evaluation should be done by examining plans (if available), satellite images, drone images, scans and by physical inspection (walkabout). A comprehensive photographic survey should be undertaken and retained for record purposes on the site inspection. This will serve as an audit record and may assist in returning the site to its original function on ACS decommissioning and closure. When scrutinising documents and conducting site inspections to confirm the suitability of a site to host an ACS, the following criteria should be taken into account.
=== Criteria ===
*Affordability (costs, including operational costs known and budget identified),
*Sufficient physical space and capacity to house the immediate need, with the potential to accommodate physical space requirements. For example, open site should not be sloping,
*Legal rights and encumbrances, including renewal opportunity,
*Good access to highway and main roads,
*Well secured perimeter and limited controlled access points,
*Proximity to other hospitals and care sites,
*Accessibility for key staff and public transport,
*Good vehicular access around the site to set up temporary equipment such as back-up generators,
*Free from clear and present danger,
*Outside attenuation zones, floodplains,
*Outside high wind zones,
*Structure in good repair,
*Effective onsite facilities management team who understand how systems work,
*Potential for expansion, if required,
*Access to sufficient capacity for
**potable water,
**adequate sewage,
**telephone,
**internet access with sufficient bandwidth,
**electricity,
*A zone for cleaning, disinfection, and decontamination of equipment at least 15 metres away from occupied areas with access to water, a hard impervious surface and drying areas in the sun, with runoff discharge into the sewer and not into marine ecosystems or the environment. Include area for cleaning and storage of cleaning equipment.
*Likelihood of acceptance of hosting an ACS by the adjacent and local community

=== Desirable ===
*Durable, cleanable surfaces,
*Large open spaces that can be converted to accommodate temporary structures,
*Good ventilation,
*On-site kitchen and laundry,
*Housekeeping staff (chemical and equipment storage, lockers, rest facility, administration office),
*Space conducive for staff respite area and locker rooms,
*Amenities with universal access,
*Fire protection safety and equipment,
*Elevator access for patients if the building has more than one floor,
*Capacity for expansion, and
*Accessible to at least two roadways to provide continued access in the event that one roadway becomes blocked on inaccessible.

== '''Infection Prevention and Control''' ==
General guidance for COVID-19 [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|Infection Prevention and Control]] can be accessed [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|here]] 

Infection prevention and control in the context of COVID-19 should respond to transmission routes of primary concern for the pathogen of interest (droplet and contact transmission, and management of risk waste) as well as infection risk of a general nature (water and sewerage, airborne transmission – under high TB/HIV burden, and general waste).
In addition to satisfying [https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html standard precautions for all patient care], transmission-based precautions should focus on three pillars: exposure reduction by spatial configuration, operational strategies, and personal protection.
=== Transmission-based precautions ===
'''Droplet and contact spread''': Transmission of SARS-CoV-2 virus occurs via droplet and contact spread. The virus has been shown to persist on surfaces for extended periods of time and is known to be efficient at infecting people. 

'''Medical waste and linen:''' As SARS-CoV-02 is carried in body fluids and faecal matter, disposal of contaminated items (tissues) and cleaning regimes (spaces, garments, linen) should be accommodated carefully in the workflow design and infrastructure provision. A site-specific waste management plan should be formulated in accordance with a site-specific waste management plan with reference to SANS 10248. 

'''Airborne transmission:''' Under exceptional circumstances, the risk of airborne transmission arises for SARS-CoV-2, as detailed below.
{| class="wikitable"
|-
!Airborne Transmission Risk Factors
|-
|
As SARS-CoV-2 is not considered airborne, respiratory protection against airborne transmission is not considered necessary, except where aerosolisation of particles may be a risk.
According to the CDC
*tracheal intubation,
*non-invasive ventilation,
*tracheotomy,
*cardiopulmonary resuscitation, or
*manual ventilation before intubation and bronchoscopy.
According to doctors in the field also when performing
*COVID-19 diagnostic sampling as patients can be induced to cough and sneeze.
*Suspected or confirmed comorbidity of TB is not an additional risk where correct COVID-19 PPE is applied.

|}
South Africa has a high prevalence of TB and HIV, and therefore, although the risk of COVID-19 transmission via the airborne route is not paramount, there is a high likelihood that undiagnosed TB infectious patients may present at the ACS for treatment. TB triage may be challenging in the ACS as there are symptoms in common (coughing) with COVID-19. This country-specific risk is taken into account in this guidance

=== Additional precautions ===
'''Water and sewerage contamination:''' The International Water Association [[Infrastructure Guidance for COVID-19/Alternate Care Sites/COVID-19 A Water Professionals Perspective|concluded]] that water and sewerage contamination is not considered to be a key risk factor for COVID-19. The panel expressed concern for “how waste and specifically wastewater (medical) would be handled by places (e.g., hostels, hotels) that are used to serve as interim COVID-19 quarantine or testing facilities or accommodation ([ACS]. These are places other than hospitals that are used in the interim for such purposes and do not usually handle wastewater from medical settings. Such facilities should be monitored carefully.” 

== '''Spatial strategies for infection prevention and control''' ==

=== Restricted access and zone control ===
The site will be arranged to establish clear zoning, with a clear restricted zone protocol and access protection. Zones should be deemed to be "contaminated" or "uncontaminated" with clear transition areas between them.

; Contaminated zones
: (also known as "dirty areas") are areas occupied by COVID-19 infected persons, PUIs, equipment, materials and supplies which have come into contact with such persons without yet undergoing a decontamination procedure. These areas will include patient ward areas and ablutions, patient admissions (including ambulance drop-off) and the associated clinical areas. Staff rest and dining facilities should be outside the contaminated zone. Limited stock for immediate use should be kept in the contaminated zone. Layout designs should consolidate contaminated zones as far as reasonable, and avoid uncontaminated zones as islands in contaminated zones.

; Uncontaminated zones
: (also known as "clean areas") are areas not generally occupied by PUIs or confirmed COVID-19 infected persons. Equipment, materials and supplies in these areas have not yet come into contact with contaminated zones or have undergone a decontamination procedure. These will include clinical management planning rooms, stock rooms, bulk stores, pharmacy, laboratory areas, kitchen and laundry.

; Transition zones
: (also known as intermediate zone) are the spaces through which transfer of people and goods from uncontaminated to decontaminated zones, and vice versa, occur. Materials from the contaminated zone should be decontaminated or contained in the transition zone. The transfer of goods and persons should be highly ritualised and, as far as possible, traffic across transition zones should be minimised. Transition areas should be strategically located to serve this function. Separation of in-going and out-going transfer of goods and persons is preferable. Transition areas include ambulance, trolley decontamination, CSSD, laundry and waste bagging areas, patient locker area and staff change areas with spaces for donning and doffing of PPE.

=== Site layout and master-planning ===
Spatial configuration and layout can ensure unnecessary cross-over of function is avoided. This entails the systematic separation of functions and the managed transition between activities to facilitate consistency of care, an orderly, efficient work environment, less waste and reduced risk for improved outcomes. To achieve this, functional relationships should first be considered at the site level before being considered at the building level. 

<gallery mode=packed heights=300px style="text-align:left">
Layout for a SARS facility, clustering functions with minimised cross-over.png|center|thumb|Layout for a SARS facility, clustering functions with minimised cross-over <ref name="Layout1">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Layout_for_a_Patient_cohorting_strategy.png|center|thumb|Layout for a Patient cohorting strategy <ref name="Layout3">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Tygerberg Hospital virus triage unit site layout.png|center|thumb|Tygerberg Hospital virus triage unit site layout <ref name="Western Cape Provincial Government, 2020a">Western Cape Provincial Government, 2020 a</ref>
</gallery>

The WHO's Clustering Layout <ref name="Layout1"/> and Tygerberg Hospital virus triage unit<ref name="Western Cape Provincial Government, 2020a"/> show worked examples of building and site layouts, which are configured with these principles, respectively. '''Cohorting''' is defined as clustering patients with similar or compatible clinical needs together for risk reduction, acuity, efficiency and quality management, as illustrated in WHO's Cohorting Layout <ref name="Layout3"/>

=== Workflow ===
Within individual functional zones, the workflow activities can be arranged to proceed from clean procedures to contaminated procedures. In the example below, the staff arrival, PPE donning, doffing and patient flows are worked to have controlled interaction and minimised cross-over

<gallery mode=packed heights=400px >
ACS HCW Flow.png |ACS Health Care Worker Flow
COVID-19 Workflow in small unit.png |COVID-19 Workflow in Small Testing Unit <ref name="Western Cape Provincial Government, 2020b>Western Cape Provincial Government, 2020 b</ref>
COVID-19 Workflow in large unit.png |COVID-19 Workflow in Large Testing Unit <ref name="Western Cape Provincial Government, 2020b"/>
</gallery>

As far as possible, a single direction flow of clean to dirty is recommended for all processes: support services, supply and waste.
The Small ACS unit workflow diagram<ref name="Western Cape Provincial Government, 2020b"/> illustrates the recommended separation of access and exit, separate waiting seats, for persons who may be COVID-19 infected. Separate spaces are provided for donning and doffing PPE. Staff change areas are provided.

In the Large ACS unit workflow diagram <ref name="Western Cape Provincial Government, 2020b"/>, there is a clear separation between staff areas and patient areas. Waiting seats are set far apart to reduce transmission risk. Staff change rooms are provided near the point of entry to the facility for staff to change from street clothes into medical work clothes. To prevent work clothes worn inside the facility from contaminating street clothes, these are kept in separate lockers. A step-over barrier from dirty to clean sides of the change room is helpful to enforce a mind-set of avoiding cross-contamination. Bins for contaminated garments are to be provided in change rooms. Shower facilities are to be provided for staff.

== '''Operational Strategies''' ==
=== Cleaning, disinfection and decontamination ===
Surface and substrate specification, and detailing of all areas should, as far as possible, allow for frequent:
*Cleaning with detergent and water.
*Disinfection with 75% alcohol solution (metal surfaces).
*[https://en.wikipedia.org/wiki/Sodium_hypochlorite Sodium hypochlorite] (1,000 ppm)/ Household bleach.
*Disinfectants listed on the EPA List N<ref>The United States Environmental Protection Agency, [https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 List N: Disinfectants for Use Against SARS-CoV-2 (Last Visited 2020) ]</ref> (for non-critical environmental cleaning).
*High-intensity ultraviolet surface disinfection (UV-C).
*Decontamination and sterilisation of clinical equipment.

=== Goods and waste management ===
Remove any unnecessary furniture, equipment and paraphernalia from all patient care and clinical areas. Provide a clear, secure space for waste management. Any potentially infectious waste materials generated at the ACS should be considered and treated as medical waste (health care risk waste). The applicable legislation is:
*[https://www.gov.za/sites/default/files/gcis_document/201409/35405gen452.pdf The National and Provincial Health Care Risk Waste Management Regulations].
*[https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf National Department of Health COVID-19 Environmental Health Guidelines.]<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>
Waste disposal bins should be positioned near the exit inside each patient rooms or wards to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another patient in the same room.

=== Materials and finishes ===
Floor materials must be:
*Level,
*Free of dust and oil,
*Impervious and smooth,
*Slip-resistant in wet areas (e.g. patient ablutions).
Smooth, cement screed floors are acceptable. Where hosting facilities have carpeted areas, a risk assessment of factors such as durability, hygiene and decontamination needs to be conducted. In cases where the acceptance of carpeted flooring is contradicted (but other factors make it a compelling option), temporary floor finishes or covering can be investigated.

== '''Personal protection''' ==
=== Hand sanitation ===
Where wash-hand basins are not provided, clinical wash-hand basins should be installed, at the minimum rate of provision of one wash-hand basin per 5 beds. Clinical wash-hand basins (see figure below) have a variety of features not present in standard wash-hand basins, which are preferable for infection prevention and control. Where standard wash-hand basins are provided, an upgrade is not necessary. In all cases, there should be no surfaces and no clutter, equipment or supplies in the vicinity of wash-hand basins, including surgical gloves.
<gallery mode=packed heights=400px>
Clinical hand wash basin.png|Handwash Basin <ref>de Jager 2020</ref>
Portable Wash-hand Basin.png|Portable wash hand basins can be provided in ACS <ref name="BDPa">BDP 2020, NHS nightingale instruction manual, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf</ref>
</gallery>

Where wash-hand basins are not available, portable units can be used, as shown above<ref name="BDPa"/>. Mounted brackets for hand sanitisers are to be provided for every two beds, preferably mounted near the foot rather than the head of the bed and at all common touch points such as entry points at ablution facilities, linen room, sluice, storerooms, medicine rooms/cupboards, near refrigerators, telephones, light switches, at entry/exit doors, etc.

=== Personal protective equipment ===
Donning and doffing points for personal protective equipment, and convenient, safe disposal of consumables to be placed at critical key points when entering patient areas.
----

== '''General transmission mitigation''' ==
=== Water and sanitation ===
To comply with National Building Regulations; Hazardous Biological Agents Regulations and National Department of Health COVID-19 Environmental Health Guidelines<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>.

=== Droplet aerosolisation ===
When designating areas for procedures during which aerosolization and airborne transmission risk is high, the building ventilation must be carefully considered to take into account downstream risks. In particular, consider to where potentially contaminated air, arising from aerosol-generating procedures, is exhausted. In general, air exhausted directly to the outside is diluted and considered safe, unless there are openings to occupied spaces near the exhaust air outlet. 

In the event that potentially occupied spaces will receive partially diluted or undiluted contaminated air, or where this is indeterminate, the aerosolising activity should be designated to an alternate area. In the event that an alternative is not available, some treatment regime (air filtration or air disinfection) is necessary. 

In most naturally ventilated settings, the airflow direction between zones may fluctuate according to the wind direction. Such high-risk spaces should not be adjacent to spaces with high susceptibility rates, such as PUI areas and uncontaminated areas. Contaminated areas should not be directly adjacent to clean areas unless mechanically ventilated. 
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|Guidance on COVID-19 building ventilation design is provided here]].

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Health, Safety and Well-being''' ==
In addition to the infection prevention and control measures discussed above, the following should be provided for health, safety and well-being.
=== General provisions ===
*Minimised and controlled entry and exit points, with suitable control.
*Clearly identified accessible and marked routes for patients, staff, goods and waste.
*Clear designation of restricted zones.
=== Site level provisions ===
*Safe staff parking and arrival of staff via planned and public transport.
*Clearly demarcated parking for people with disabilities.
*Arrival and departure point for patients via public transport, passenger vehicles, and emergency service.
*Limited safe patient parking.
*Supply of goods and removal of waste.

=== Within and between buildings ===
*Entrances with a clear opening width (CoW) of at least 900mm.
*Routes with a minimum width of 2 000mm free of hazards, for example, rubbish bins.
*All clinical, patient and support areas to be accessible by trolley.
'''Ramps''' should be of stable construction, capable of sustaining a mass of 300kg. They should incorporate side lips and the surface should be slip-resistant. Gradients should be as gentle as the circumstances allow. (Recommended maximum 1:20). 
'''Small changes in floor levels''' are not desirable, but where these exist are to be clearly marked with reflective paint/ tape, and lit at night
Elevators between different floors, where patients need access (The recommended minimum lift size for patient trolley/stretcher movement is 1 400mm × 2 400mm, however, this may not be possible). 
'''Pathways''' to be lit at night, where used at night. 
'''Staircases''' must be well-lit at night with non-slip surfaces and secure balustrades. 
'''Doors''', Double doors and automated or push-operated doors to all clinical areas are to be preferred, where these are newly installed or able to be retrofitted. Door closers are to be disabled, where not necessary to reduce touch surfaces. Hand sanitisers to be provided at where high touch common surfaces occur (e.g. wall-mounted at doorways).

=== Signage ===
The appropriate level of information to facilitate legibility, orientation and wayfinding. Minimum standards, signage to be:
*Clearly visible, simple font, font size, contrasting colours, placed in the field of vision
*Washable
*Comprehensive safety signage - fire signage (exits, equipment etc.)
*Restricted areas clearly marked
*Identification signage - each patient space to be allocated a unique number and a whiteboard or perspex sheet for writing the patient’s name
Signs should be posted immediately outside of patient rooms indicating appropriate IPC precautions and required personal protective equipment (PPE).
Signage of a temporary nature can be provided on laminated white A4 sheets attached eye-level. The text should be black sans-serif (for instance Arial) text at least 40point size and centrally positioned on the sheet. Detailed guidance on signage is provided in IUSS Inclusive environments.
=== Safety and security ===
Upon identification of the ACS host site, a team should be convened to conduct a multidisciplinary safety and security analysis. These critical team members need to form the working committee responsible for undertaking the detailed assessment of the existing facility’s security. They should analyse data about the security system’s condition and review existing security concerns or issues that are reasonably likely to become concerns in the near future. The figure below represents a five-zone approach to security, which is a recommended, systematic approach to security.
[[File:Zonal approach to security.png|center|600px|thumb|IUSS Security- Zonal Approach to Security <ref name="IUSS Security">IUSS Hospital design principles - Security [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file]</ref>]]
The security strategy should take into account that whilst clinical services and some logistical and support services will be required 24 hours a day, seven days per week, some support services, logistics services and auxiliary services may only be operational for the minimum periods required to meet demand. These functional elements should be capable of being secured, for example over weekends and at night, as the case may be.
Detailed guidance is available in [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file IUSS Hospital design principles - Security] <ref name="IUSS Security"/>

=== Comfort and dignity ===
Supplemental heating: Patient health and comfort are dependent on, amongst others, maintaining body temperature. The ACS structural technology must be selected to achieve the general indoor environment conditions discussed in a subsequent section for all clinical and occupied areas. As we are moving into South African winter supplemental heating may be required, especially in the evenings, in order to avoid hypothermia. Use of fans, bar, radiator or gas heaters should be prohibited. Unless clinical areas can be maintained above 18 degrees centigrade, patients should each have an infrared heater available, in addition to blankets. Personal/ donated blankets can be considered if they are laundered first and could be destroyed upon discharge.
Mobile screens should be available to provide privacy where necessary (e.g. during consultations or procedures).
<gallery mode = packed heights = 400px>
Bed_Isolator_-Vietnam.png|thumb|Flexible Barrier Isolator<ref>WHO. (2020), Severe Acute Respiratory Infections Treatment Centre. Geneva, Switzerland : WHO- World Health Organization</ref>
ACS Cohort beds.png|ACS Cohort beds.png|thumb|Excel Centre London 04-2020 <ref>Architects' Journal 2020, [https://www.architectsjournal.co.uk/news/nhs-nightingale-bdp-on-the-first-nine-days-converting-the-excel-centre/10046749.article https://www.architectsjournal.co.uk/news]</ref>
</gallery>
Some solutions which address patient privacy and dignity are depicted above.

=== Notes ===
<references/>

== '''Schedule of Accommodation''' ==
Based on clinical needs of the ACS, a schedule of accommodation can be crafted capturing the clinical, clinical, logistical, support and auxiliary services associated with the render of care. When deriving a schedule of accommodation, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital tool can be used. Functions to be accommodated are: 
'''Clinical services''': Triage, rapid assessment of persons entering the facility, to expeditiously identify and render the appropriate service. Admissions and registration. Inpatient accommodation is to be organised according to cohorting principles, discussed above. Testing and diagnostics, including laboratories and x-ray. Safe storage and dispensing of drugs to patients.Offices for clinical administration and clinical planning meeting rooms in the clean zone are needed. 
'''Logistical services:''' Logistical services will entail management of flows of people, goods, services and information to and from the site, as well as within the site. It includes security and communication arrangements. Staff entry, preparations to transition from outside to clinical work environment, including pause areas for relief. Emergency services, visitors. Goods, supplies and storage and waste removal and/ or treatment.
Support services key to the provision of clinical services should be separated so that the risks associated with that particular activity can be managed. 
'''Support services are:'''
*Laboratory services
*Catering
*Laundry
*Environmental cleaning and housekeeping
*CSSD
*Maintenance and cleaning of surrounds, eg. waste areas
*Porters/”runners”, stretchers/wheelchairs
*Mortuary
* Security
Support services can be provided off-site, in which case, safe, secure and efficient transfer and logistical arrangements should be designed. 
'''Auxiliary services:''' Auxiliary services are services which may be provided on or near the ACS site, but which are not directly related to core clinical care. This included overnight accommodation for staff who may not wish to return home to avoid exposing their families, or who need rest between shifts, or for discharged patients awaiting transport home, volunteers who have recovered from SARS-CoV-2.
Limited psychosocial services and allied health services may also be provided on or near ACS for example by approved partners.
Examples of schedules of accommodation for patient and support spaces for a protective isolation ward is available [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedule for COVID-19 Isolation Wards|here]] and mild to severe cases [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedules for COVID-19 Wards for Mild to Severe Cases|here]].

== '''Clinical Services''' ==
=== Triage ===
Confirmed COVID-19 cases and PUIs who are referred from a testing facility or a higher level of care, will enter the facility in a triage area to receive vital screening and initial assessment. They will be registered and admitted to inpatient care. They will be assigned a "ward" or section of the facility - based on disease status and acuity. These are Protective Isolation, the Mild & Moderate ward, or the Critical & Severe wards. Patients should be clustered according to gender. As far as practicable, ablutions for each gender, isolation patients, paediatrics and staff shall be separately provided. Paediatrics patients, if admitted, are to be assigned a dedicated section.
As patients recover or deteriorate, they may be relocated to the appropriate section/ ward.
Once the patient has sufficiently recovered and a negative test result is received they will be appropriately decontaminated and discharged, collecting medication from the dispensary on exit. Patient movement between various sections of the ACS will be restricted as far as possible, with mobile radiology units, in-ward medication dispensing and in-ward food service.

=== Inpatient ACS accommodation ===
Separate spaces for:
*suspected, unconfirmed cases, under observation (PUIs), to be accommodated in isolation facilities (separate rooms, if possible);
*patients with confirmed COVID-19 with mild to moderate disease, not requiring dedicated oxygen therapy;
*patients who require dedicated oxygen therapy;
*patients requiring mechanical ventilation; and
*recovered/ confirmed negative.
==== Protective Isolation Facilities ====
Suspected, unconfirmed cases, under observation – persons under investigation (PUIs) to be accommodated in protective isolation facilities (separate positive-pressure rooms, if possible). PUI are restricted to their rooms. All food and laundry services will be brought to the PUI rooms to reduce interaction and potential contamination. All waste will be collected by facility staff and taken to waste handling areas. Infection prevention and control measures are put in place for the handling of used food utensil and laundry as well as waste collection. PUI areas will have restricted access, including for staff serving other inpatient sections, for confirmed cases.

==== Inpatients accommodation for confirmed COVID-19 ====

Inpatient facilities confirmed positive COVID-19 can be accommodated in large shared ‘wards’ with partitioning between patients. Partitioning between patients is optional. Partitioning is preferable to curtains found in conventional hospitals, as they are more conducive to daily cleaning. If curtains are used, antimicrobial treated fabrics with biocide used to treat the curtains has been tested to international standard EN 14476 and shown to be effective against H1N1 Influenza A Virus (Swine Flu), >99.999% kill rate in 5 minutes and measles morbillivirus, >99.99% kill rate in 5 minutes are preferred. If only separate rooms are available, patient monitoring and surveillance will need to be accommodated. This phase of treatment has a lower area/space requirement compared with PUIs, as cross-infection between patients is less of a concern. Shared ablution facilities are acceptable. It is recommended that, at least, two general accommodation ward areas be provided. 

a) Mild and moderate patients, and 
b) Serious and critical patients. 

The room must have openable windows for natural ventilation if a dedicated positive pressure ventilation system is not available. Ducted ventilation systems shall not be shared between PUI areas and confirmed COVID-19 patient areas. 
[[File:COVID-19 ACS - protective isolation – bed layout.png|thumb|center|800px|ACS - protective isolation – bed layout]]
[[File:COVID-19 ACS – mild-moderate patient bed layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient bed layout]]
[[File:COVID-19 ACS – mild-moderate patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient shared ward layout]]
[[File:COVID-19 ACS – severe-critical patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – severe-critical patient shared ward layout]]

Examples above show bed layout with bed spacing for protective isolation, a mild/moderate patient and a mild/moderate patient shared ward and for a severe/critical patient

=== Patient services ===
Patients in ACS will not generally be ambulatory and will be confined to their room, or cubicle in a bed. In general, domestic beds or hospitality industry (hotel) beds are not suitable for patient care. These should only be used where a hospital-grade bed cannot be sourced, as hospital beds are designed for ease of cleaning and decontamination (for infection prevention and control) and with patient and ergonomics, safety and comfort taken into account (they prevent back injury for nursing staff and can help to prevent bedsores). The higher the specification of bed, the more suitable it is for the higher levels of care. Lockers for patients personal belongings should be provided in the uncontaminated zone (in which case bedside lockers will not be necessary), and it is preferable (where bedside lockers are not provided) for overbed tables to be provided, per bed, if possible. 
The following beds are suitable:
*Repaired and refurbished beds from condemned hospital stocks.
*South African National Standard, SANS 521:2013 Edition 3.5, on Hospital beds and cots ISBN 978-0-626-28830-3.
*Beds listed on the National Treasury (See [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Hospital Bed Specification|specification]]).
The table below details the minimum services required at each patient bed. Details on these services are discussed in a subsequent section of the document.

{| class="wikitable"
|-
! Service/ Capacity!!Triage!!Isolation !!Mild – moderate inpatient!!Severe case wards!!Critical case wards
|-
| Power – 16A 230V Single socket outlet||As needed ||1 per bed||1 per bed||3 per bed||6 per bed
|-
| UPS Power – 16A 230V Single socket outlet ||As needed||1 per bed||1 per bed||1 per bed||2 per bed
|-
| Medical Air<ref group="Note">Mobile units recommended for intermittent use. 3 per 20 beds</ref><ref group="Note">There are some ventilators which have built-in compressors allowing them to function without Medical Air. This is however, not the norm. With Ventilators probably being the most difficult medical device to obtain at present, it would be prudent to rather allow for Medical Air at each bed.</ref> (LP)400kPa||No||Yes||No||Yes||Yes
|-
| Medical O2 -400kPa||Portable/shared||Portable/shared||No||One||Two
|-
| Vacuum-40kPa||No||Portable/shared||Portable/shared||Yes||Yes
|-
| Equipment rail||||||||Yes||Yes
|-
| Upper room UVGI||Optional||Optional||||||Optional
|-
| Examination light||No||No||Yes||Yes||Yes
|-
| Room Ventilation rate||60 L/s per person||10 L/s per person||10 L/s per person||10 L/s per person||12 ACH
|}
'''Notes: '''
<references group="Note" />

Two additional 16A 230V single socket outlets, one two-pin outlet and a worktop should be provided for every 32 beds (or part thereof), for:
*Electrocardiograph (ECG): Could be omitted if monitors have a full 12 lead ECG function.
*Blood gas analyser: Could be omitted if a Lab Services are available.
*Staff cellphone charging.

Example of healthcare technology to be provided for critical care patients is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]. Severe patients may be provided continuous positive airway pressure (CPAP). Emergency trolleys (“crash carts”) are to be provided in patient areas with convenient access to patient beds, out of the passage of corridors and is moved to the patient when needed. 1 crash cart for every 16 patients (or part thereof, with at least one dedicated for PUIs. An example of provisions for a crash cart is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]
==== Patient ablutions ====
[[SARS-CoV-2 is found in faecal matter]], so careful management of patient body fluids is crucial and convenient, practical support for frequent cleaning of ablutions especially shared ablutions is necessary. Dedicated ablutions (toilets and showers) are to be provided for patient use. Toilets and showers should be in separate rooms.
Hand washbasins and or/ hand sanitiser should be provided both inside and outside the toilet room so that patients can wash their hands on the way in and on the way out of the room.
*1 toilet for every 8 persons.
*1 shower for every 8 persons.
*1 disabled ablution for every 8 regular ablutions (or part thereof).
*1 disabled shower for every 8 persons (or part thereof).

Critical and severe patients may be sedated and have a reduced need to access ablutions, ablution facilities proximity and provision can take this factor into account. Showers and wash hand basins should have hot and cold running water. Where possible ablution facilities must have openable windows for natural ventilation, if not possible the bathroom extraction and room ventilation system must be reviewed before admitting patient '''(see [[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|ventilation]]).'''

Portable toilets and showers may be used, provided that suitable hand wash facilities are provided. These will need to be suitably located, preferably in decentralised clusters, so that patients can easily access them without needing to walk very far. Ablutions should be located and designed in such a way as to provide visual and acoustic privacy, dignity and avoid disturbance of other nearby patients when accessing, using or cleaning the ablutions. Separate ablutions are to be provided for PUIs and confirmed patients.

====Makeshift sluice areas ====
In conventional hospital settings, sluice rooms are provided for cleaning and sanitation of soiled equipment, such as bedpans. In a temporary setting, such as an ACS, the establishment of a temporary sluice room may not be practicable, and there may not be facilities for emptying buckets, rinsing equipment etc.. The following is suggested:
Allocate a toilet, hand wash basin, not in splash range and restrict access to it for draining buckets and install a macerator for disposal of disposable bedpans. Electrical, water and waste supply points required as per supplier specification.
==== Dedicated patient treatment areas ====
The following dedicated, private spaces per ward for clinical procedures are recommended:
*Counselling and consulting room (can be shared), as shown in the figure below
[[File:Consulting room example layout.png|400px|thumb|center|Consulting room example layout]]
*Minor procedures room, as per the example provided in the figure below 
[[File:Treatment-minor procedures room example layout.png|400px|thumb|center|Treatment / minor procedures room example layout]]

== '''Logistical Services''' ==
=== Communications ===
Electronic communication should be facilitated in all zones of the ACS by the provision of device charging stations, and wifi.
=== Visitors entry point ===
Visitors are strongly discouraged from entering the ACS.
*In paediatric wards, one parent may be accommodated to visit a patient. In such cases, direct access for the visitor should be provided so that the visitor does not need to pass through the general patient area. Appropriate PPE must be donned before entering the patient area and hand washing/sanitising must be done when exiting the area.
*Non-patients who are accompanying suspected patients to the facility for testing or admission must be accommodated in a well-ventilated, spacious waiting area. Signage in such waiting areas must inform visitors about symptoms, hand hygiene and PPE.
*Hand washing/sanitizing facilities should be provided.

=== Staff areas ===
==== Staff change rooms ====
A minimum of 9m² or 4m² for a single person, increasing by one m² for each additional person is required. The clean (street side) and dirty (contaminated facility side) of the change room should be separated by a step-over barrier.

==== Staff rest areas ====
Staff rest areas within the main facility should be provided with access to kitchenette facilities and staff ablutions.
=== Staff auxiliary services ===
'''Staff on-call:'''Since staff may be required to work long hours or could be required to be on-call, shared, overnight sleeping facilities can be provided for staff on duty, outside the contaminated area, but in close proximity on the patient areas. An example is set out in the diagram below.
[[File:Example of on-call sleeping area for staff.png|center|600px|thumb|Example of overnight sleeping area for staff]]

'''Staff accommodation:''' It is advisable to provide some staff accommodation for off-duty staff who may not have suitable alternatives, for example homes too far away, transport limitations or the requirement not to expose family members to risk. This should be provided in the vicinity of the ACS, but in a physically separated zone. This amenity can be outsourced.

== '''Support Services''' ==
=== Workflow principle ===
[[File:Linen processing cycle.png|none|thumb|Linen processing cycle <ref>IUSS 2014 [https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department]</ref>]]
Progressive workflow from “dirty” (that is contaminated) to “clean” linen is advisable to reduce the risk of exposure to contaminated materials. The workflow diagram below, showing the progression from the dirty linen receiving area, to the cleaning process, to decontamination and drying, and finally sorting and packing, and storage, illustrates this principle.
=== Laboratory ===
[[File:Example of modular laboratory.png|right|thumb|Example of modular laboratory]]
The WHO recommends the following laboratory diagnostic equipment be accommodated:<ref>WHO 2020, [https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items]</ref>.
<nowiki>• Lab screening test kit
• Lab confirmation test kit
• RT-PCR kit
• Extraction kit
• Cartridges for RT-PCR automatic systems
• Swab and Viral transport medium
</nowiki>
Additional accommodation requirements are:
# Reception counter- receiving specimens
# Testing with perspex/ glass screen
# Receiving/Data capture
# Specimen holding
# Toilet - staff
# Blood storage fridge
Can be provided as a modular laboratory unit as shown in the diagram.
=== Pharmacy ===
The purpose of the pharmacy is to provide medicines needed for inpatient treatment and care.
All medical supplies should be stored in a secure, climate-controlled area in close proximity to the patient treatment area. The pharmacy must have dry, lockable, climate-controlled storage of medications. Most pharmaceuticals are labelled with storage temperatures. The pharmacy should have adequate ventilation through an openable window to prevent humidity from building up in the room. Air-conditioning or mechanical ventilation can be provided, if necessary.

Dispensing areas must be well lit. Worktop in space for stock records and administration. Dispensing counters to have perspex or glass screens to serveries. Social distancing implemented at counter, between pharmacists/assistants and between chairs in waiting area.

Can be provided in a mobile unit.

=== Radiology ===
The purpose of radiology services is to provide chest X-Ray services for COVID-19 diagnostics. In general, CT scans, bucky rooms etc. associated with some radiology equipment require specialised infrastructure and therefore is not suitable for ACS. Radiology services can be provided as a mobile floor standing unit, or containerised unit. Alternative technologies such as Lodox and hand-held ultrasound devices are being investigated as potential options and could be confirmed as suitable for use in due course.
=== Laundry services ===
All dirty linen should be handled for bagging or binning inside the patient room/cohort area. The clean linen stock should be stored conveniently close to clinical areas, in a dedicated clean area in the uncontaminated zone. Used linen should be stored in a designated, safe, lockable holding area while awaiting collection. Interim storage areas for soiled linen at the wards is allowable; this may be in dirty linen/ utility room.
Any clean linen for PUI areas should be handled in spaces physically separate from dirty linen of confirmed patient areas. It may be necessary to completely separate PUI and confirmed patient linen streams. Soiled linen and clean linen bags and bins should be dedicated and not mixed.
Full laundry cleaning and drying services may be provided on-site or outsourced. If laundry cleaning and drying services were already rendered on or for the host site before it is repurposed as an ACS, then a suitability and risk assessment should be conducted to ensure that the volumes of laundry generated and infection prevention and control measures are conducive and modifications made as necessary. A new full laundry service may take time and resources to establish, and in general, will not be established at a host site as a temporary solution. Where the site and circumstances advocate for the design of a new laundry or the upgrade of an existing laundry, the IUSS Laundry Services for Hospitals should be applied.
==== Siting and model selection considerations ====
When an existing laundry is being assessed for use or a new one is being planned the following considerations apply:
* Water and power capacity.
* Ease of access to the ACS’s main corridors and internal transport routes.
* The noise factor of the facility and its impact on nearby patient care departments.
For outsourced departments:
* Delivery areas to allow sufficient space to ensure that vehicles can manoeuvre and park easily at the reception and dispatch bays.
* Access to the ACS service roads and public roads.
==== Functional requirements ====
The most basic equipment needed in a laundry includes washing machines, tumble dryers and ironing machines. Equipment requiring steam is not recommended for a temporary facility. The sizing of the laundry, equipment and engineering services can be modified based on the principles provided in the IUSS Laundry and linen.
=== Catering services ===
Kitchenettes, that is, areas for tea, coffee and snacks, mainly for staff, in staff pause areas are discussed elsewhere in this document.
Catering services (for staff and patients) may be provided on- or off-site. If the ACS is to be established with easy access to a suitable, existing, functional kitchen service (e.g. hotel, military or hospital catering) which can meet the additional demand of the ACS, then this should be used. If there is no suitable facility, catering should be outsourced via a suitable off-site supplier. Only in the event that no feasible or suitable, existing facility or local supplier is available, should a new catering service be established at the ACS. Detailed guidance for the sizing, design and layout of catering services can be found in the IUSS Catering Services for Hospitals.
The kitchen (for on-site catering) or preparation area (for off-site catering) should be located with easy access to the point of delivery and storage of food. Adequate food and equipment storage space must be provided.
It is recommended that patient and staff meals, where provided, be supplied in disposable, containers, suitable for incineration, and that these are disposed of as risk waste immediately after use.
Where off-site catering is used, a suitable area for receiving should be provided. Space will be required for sorting meals for distribution and collecting and storing dirty dishes, washing dirty dishes, if necessary, and disposing of left-over food and disposable containers and utensils. The size of the areas required for this will depend on the number of meals delivered.

=== CSSD ===
The primary function of a Central Sterile Supply Department (CSSD) is to provide an efficient, economic, continuous and quality supply of disinfected and sterilised items, when needed, to all patient-care service points in the ACS, and to receive returned contaminated items for cleaning.
CSSD with limited sterilisation capacity (autoclave) but sufficient disinfection capacity (instrument washing). The layout requires a designated clean and dirty areas with a hard barrier between to avoid cross-over of staff and equipment. Work is unidirectional - flows from dirty – to clean - to sterile areas.
This yields three distinct zones:
1. Receiving and cleaning with pass-through windows
# Dirty receiving with Perspex or glass partitioning
# Dirty utility
# Decontamination and cleaning/wash area with throughput instrument washing
# Trolley wash/Park – external
2. Inspection, assembly and packaging with pass-through windows
# A tabletop autoclave
# Instrument washer
# Clean Packing area
3. Sterile processing, storage and distribution. (Separate issuing area from receiving area) with pass-through windows
# Store -linen and consumables
# Sterile pack store
# Issue - Collection hatch with Perspex or glass partitioning
Must also have a secure, separate receiving area for consumables receiving and storage.
An example of a CSSD unit is shown in Figure 21.T

[[File:An example of a small CSSD facility.png|600px|thumb|none|An example of a small CSSD facility<ref>IUSS 2014, https://www.iussonline.co.za/norms-standards/support-services/24-central-sterile-service-department</ref>]]

To be understood: Quality of services, eg. water (including a source of distilled or ionised water for rinsing of bronchoscopes) and electricity, quality of management, if equipment is appropriate for needs and fit for purpose, what is required of the equipment in the near and far future (relocation?), compliance with S.A. National Standards for CSSD, compatibility of equipment and devices, correct chemicals, maintenance of equipment, training of operators. Although the use of disposable breathing circuits and accessories (masks) should be encouraged, the capacity to disinfect these items if disposable is not available must be considered.

The CSSD must be sized to serve the ACS. Considerations are workload and space requirements. CFSA has extensive [https://www.fidssa.co.za/Content/Images/CFSA_SOP_2018.pdf standard operating procedures] for CSSD.

Workload: Number and type of procedures, number of procedure rooms, eg for bronchoscopy, operating hours, available inventory, volume of work and peak times, degree of mechanization, eg. manual or automated instrument washing, amount of product to be stored – chemicals, barrier wrap, chemical indicators, etc., storage and distribution records, quality records – eg. equipment checks, disposal needs.

Space requirements: Space for separation of clean and dirty, allow for unidirectional movement, allow space to manoeuvre trolleys (queue, pack/unload), reduce lifting and carrying heavy items, reduce awkward movements, allow for tidy work areas. Insufficient space will compromise sterility!

Preference should be given to construction materials and finishes which are suitable for frequent cleaning and tolerant to chemicals, including bleach (sodium hypochlorite). Impermeable flooring, non-slip and smooth washable walls are needed. Joints at walls and floors and coving at wall edge, and exposed drains should be avoided. Worktops should be sealed and should be ergonomically suitable.

Ceiling heights below 2.8m may be vulnerable to damage from humidity Where steam and moisture are generated. Noise – insulation of washer-disinfector and steriliser in technical walls will reduce noise. Lighting: Natural light if possible – windows sealed. High luminance if artificial lighting. Open, slatted shelves for sterile store area. Sinks for manual washing: At least two basins, deep (25cm at least) basins, 91 cm from floor, wide and long enough for the biggest instrument tray or container, water ports for flushing of lumens.

The CSSD space allocation and layout should be determine based on what procedures and which medical devices will be required. A typical [[equipment list is provided here]].

=== Maintenance and cleaning ===
Maintenance and cleaning services must be accommodated with offices located away from clinical areas.

=== Mortuary services ===
The National Department of Health has issued guidance on handling of dead bodies and infectious remains<ref>National Department of Health South Africa, 2020 [https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf]</ref>, which should be applied to ACS. While some guidelines have recommend that bodies of persons who have died from COVID-19 should only be held for a very brief period prior to cremation or treatment for burial<ref>Zhejiang University, 2020 [http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm]</ref>, the WHO holds the view (at the time of writing) that there is no evidence of persons becoming infected from exposure to bodies during normal ceremonial and burial activities. However, appropriate PPE should be used when handling such bodies with additional airborne precautions to be taken during autopsies<ref>WHO, 24 March 2020 [https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf]</ref>.

Either body cabinets or a refrigerated room could be used for body storage.
==== Location and layout of mortuary service ====
It is likely that not all alternative care sites will have a mortuary. Those without a mortuary must have a holding room that is located away from general access areas. This holding room must be suitably sized and conditioned. A recommended room size is 3.5 m x 3.4 m<ref>IUSS Adult Inpatient Services, 2014, [https://www.iussonline.co.za/docman/document/clinical-services/65-adult-inpatent-services-gazetted/file]</ref>
A mortuary should be located so that it is easily accessible to mortuary staff and related service providers and visitors without presenting either aesthetic, emotional or ethical problems for unrelated staff, patients or visitors. It should be separate from the general facility, allowing access for the family to view a body without passing through any potentially contaminated area of the facility. The visitors’ entrance should be external and completely separate from other access points.
Appropriate routes should be designated so that bodies are not moved through public-access areas.
==== Sizing of mortuary ====
The layout and size of a mortuary are largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.
==== Services ====
The following services are required in a mortuary:
* Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.
* Sluicing facilities are to be provided in both the body-preparation and autopsy areas if they are not a common area.
* Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush-fitted stainless steel grids.
* No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.
* The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.
* Anti-backflow devices should be fitted to the water-supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.
* Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.
==== Finishes ====
Wall and floor finishes should be impervious to liquids and easily cleanable.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Environmental Controls''' ==

== General Indoor Environment Conditions ==

Existing environmental control systems should be modified to suit requirements in the facility. The following issues should be considered:
* Systems should be set to maximise the introduction of fresh air and maintain the pressure regime (see ventilation).
* The following internal temperature range should be maintained 19 - 24oC.
* Cooling systems should be able to cater for projected internal heat gains from people, lighting and equipment. Indicative heat gains in treatment areas are 8W/m2 from people, 15W/m2 from lighting and 3 W/m2 equipment and in critical care areas 16W/m2 from people, 15W/m2 from lighting and 60W/m2 equipment.
*As heat gain can vary widely between items of equipment, heat gain and utilisation rates for equipment should be obtained from the manufacturer to establish this more accurately.

=== Solid waste from ACS ===
According to the National Department of Health COVID-19 Environmental Health Guidelines
“All solid waste from the facility should be regarded as potentially infectious material and therefore appropriate precautions should be taken". The management of healthcare risk waste (HCRW) should follow the correct identification segregation, storage and disposal processes as indicated in SANS 10248-1.

* HCRW is segregated at the point of generation and shall be containerized to minimize the risk of contamination.
* Waste generated from patients in isolation or quarantine in a designated facility health facility is treated as health care risk waste (HCRW) as per SANS 10248-1-2008.
* The HCRW is properly packaged in a sealed, leak and puncture-proof containers/ boxes.
* The HCRW is labelled with the biohazard symbol/ sign and marked “Corona virus or COVID-19”.
* The HCRW is stored separately from other waste generated.
* The collection, transportation, treatment and disposal is provided by only an appointed/ appropriate contractor/ service provider, however, ensure that waste is safely stored until the health care waste management company can pick it up and that the company knows and acknowledges that waste was generated by suspected or confirmed COVID-19.
* The waste management company collecting must ensure that and treated and disposal is conducted at license waste treatment/ disposal facilities .
* All personnel or staff in contact with patients must be geared with appreciate personal protective equipment (PPE’s) at all times to prevent exposure or risk to health.
* Monitoring should be done at such facilities.
* All, bags, bins and boxes must be adequately sealed, as not to leak any fluids, and must be wiped down with 0.05% chlorine solution

Measures developed should consider the following.
* Develop a waste management plan following national guidelines and best practice standards for the disposal of medical waste (WHO, 2020).
* Establish procedures with medical waste service providers to regularly pick up the waste and dispose of this safely.
* Provision should be made for 5kg of solid waste per bed per day and this should be monitored and supplemented where it appears this may be inadequate.
* Ensure that access to waste is secure and controlled, for instance, by using lockable waste 1000l containers kept in a location that can only be accessed by health facility and nominated service delivery staff.
* Vermin control programs must be implemented throughout the site with HCRW collection points prioritised
* Provision for safe cleaning and disinfection of reusable containers should be provided. Cardboard, single-use HCRW boxes are removed from site and incinerated.
* Waste must not be allowed to accumulate or be stored inappropriate or unsecured containers.

== '''Engineering Services''' ==
Engineering services include patient services, ventilation, electrical power, water, medical gases, oxygen, compressed air, vacuum, lighting, and fire safety that support the needs of the patients and medical staff under normal and emergency situations. Good practice standards are provided in:
* IUSS Building Engineering Services<ref name = "IUSSBES">IUSS 2017, [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file]</ref>
* NHS Nightingale Instruction Manual<ref name="BDP2020">BDP 2020, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf]</ref>.
The guidance below draws on these and other manuals and standards. 

=== Building ventilation ===
==== Mechanical ventilation ====
While SARS-CoV-2 RNA has been detected in aerosol form, in experimental mechanical aerosolization studies, it is primarily spread through droplet and contact spread and the potential for airborne transmission is thought to be low.
However, the following advice is provided by ASHRAE regarding HVAC systems in general spaces (not specific to healthcare):
Effective high levels of ventilation must be achieved in the facility. Existing ventilation systems should be tailored to suit internal layouts and requirements and the following measures should be taken.
* Mechanical systems should be set to maximise fresh air supply to the facility. There should be no recirculated air without HEPA filtration or other validated decontamination processes.
* A pressure regime should be established, as shown in figure 2, to 'push' air from clean areas, to dirty areas and then out of the building.
* A clean air supply of over 10 L/s per person should be targeted for odour control.
* Fresh air supply shall not be located near patient beds to avoid drafts in winter.
* Extraction points can be located near patient beds in isolation wards or at a high level in long-stay wards. Short-circuiting of air between high-level supply and extraction is a performance risk in winter.
* Noise from ventilation systems and fans shall be below 45 dBA
* Protected lobbies, internal partitions, door arrangements, fans and extracts should be used to maintain the pressure regime and airflow as indicated in the diagram below.
 

[[File:Ventilation in temporary facilities.png|600px|thumb|none|Ventilation in temporary facilities<ref name="BDP2020"/>]]

==== Natural ventilation ====
The airflow direction between naturally ventilated zones may fluctuate according to the wind direction. This is not of concern within and between contaminated zones where occupants are either protected with mandatory PPE or confirmed to be infected with disease strains similar enough so as not be able to reinfect others. Where levels of occupant susceptibility to an airborne disease is significantly different, the less susceptible areas (such as PUI areas and uncontaminated areas) shall be protected from the naturally ventilated and contaminated areas by mechanical ventilation systems with a capacity sufficient to overcome the expected natural ventilation pressure fluctuations (typically 5-15Pa). Where such mechanical ventilation systems are not feasible or expected wind pressure is too great, zone adjacently must be avoided.

===Ultraviolet germicidal Irradiation===
The application of Ultraviolet Germicidal Irradiation (UVGI) for room air disinfection is well understood and is proven to be effective in the disinfection of microorganisms including M. tuberculosis (TB) in air. UVGI should, therefore, be considered as a valid element in indoor airborne infection control strategy for high volume settings. Studies have demonstrated the importance of good vertical air mixing in the room, and the safety of UVGI application. In areas where UVGI is indicated, the design and development of UVGI systems should be in accordance with the [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]<ref>van Reenen et al,2019 [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]</ref>

=== Electrical power ===
Sufficient and reliable power must be available at the facility for envisaged medical equipment, medical gases, lighting and building ventilation equipment. Power installations for the temporary facility can be divided into three zones as indicated below. These are existing services, the temporary service zone and services in each bay.
The following should be considered by competent engineering professionals.

=== Existing services ===
*Capacity: Evaluate whether sufficient power to accommodate envisaged medical equipment, additional lighting and heating, building ventilation and air conditioning can be provided. If existing capacity is insufficient, investigate if it is possible to route additional power from additional locations/transformers around the site or from adjacent sites.
* Safety: The existing electrical distribution network must be able to supply the required equipment load. If this is insufficient/appears unreliable, identify how this can be supported.
* Resilience: Evaluate back-up power and a UPS capacity against essential services demand. If existing capacity is not sufficient, source and establish temporary service capacity.

=== Temporary service zones ===
*Identify locations for temporary service zones where equipment can be located.
*Ensure that equipment and maintenance access is safe and easy.
*Ensure that all distribution boards, circuit breakers and cables are clearly labelled.
=== Services in each bay ===
*Provide pre-wired power strips/trunking as per bay requirements.
*Check that these include sufficient electrical outlets and service points for envisaged equipment.
*Ensure that trunking will carry required equipment loadings. The IUSS Building Engineering Services Guide can be used to check requirements<ref name = "IUSSBES"/>.

[[File:Layout_of_power_in_a_temporary_installation.png|600px|thumb|none|Layout of power in a temporary installation <ref name="BDP2020"/>]]
----

=== Water ===
Water points are needed for handwashing, showers and cleaning. The following issues need to be taken into account.
==== Supply ====
Onsite cold water storage, dedicated to the domestic water requirements of the facility, should be provided. A minimum usable volume of 500 litres per bed should be available.
Hot water storage and consumption should be confirmed by an engineer, as follows:
*Storage 25 L per bed.
*Consumption 180 L/bed.day W/O laundry; 250L /bed. day W laundry.

==== Handwashing ====
See infection control for clinical wash-hand basins
==== Showers ====
Showers for staff coming off shift should be available. Staff flow routes exiting contaminated treatment areas should pass through gowning and shower areas.
----

=== Medical gases, oxygen and vacuum (suction) ===
Medical gases, oxygen and vacuum services will be required in the facility. Mobile gas supply requires piping between supply and patient and clutter floor space. Preferably used fixed installations for patient rooms/cubicles, if possible.

System capacity and point of use pressures and consumption rates are to be ensured at all points. WHO provides technical guidance on [https://www.who.int/publications-detail/oxygen-sources-and-distribution-for-covid-19-treatment-centres oxygen sources and distribution]. 
[[File:Medical gas service layout.png|6oopx|thumb|Medical gas service layout<ref name="BDP2020"/>]]
The following points should also be taken into account.
* For centrally supplied medical gas and vacuum services, system resilience and availability must be ensured.
* Compressors, tanks, accumulators, VIEs, headers and controllers must be secured from uncontrolled access.
* Where possible, gas piping should be reticulated below floors or in ceilings to ensure protection from tampering, damage and ease of access.
* Where reticulation is within open areas, high-level reticulation with point-of-use droppers is advised. Low-level reticulation within rooms is to be avoided.
* Flexible piping can be used, ensuring it does not present a contamination or fire risk and should comply with local regulations. Special care should be taken with flexible O2 piping, keeping it to a minimum.
* Vacuum piping may be contaminated, where point-of-use filtration and collection systems fail. Precautions should be taken when demounting or disconnecting temporary vacuum lines.
* Ensure that oxygen pipelines are designed to provide sufficient flow to all oxygen points in the facility. In terms of utilities, oxygen and medical air would be required. A temporary vacuum point can be provided by mobile medical vacuum units distributed throughout the unit.
* Mobile medical air supplies should be considered where reaching piped specifications are not feasible. Where flexible hoses are used for oxygen and medical air special precautions need to be taken. Flexible oxygen piping must be chemically safe for O2 use. Where perishable flexible piping is used for medical air, terminal filtration at the point-of-use may be required at point-of-use. Especially for long-term use.
* Electrical and gas services can be reticulated against pipe racks or boards fixed to the bed-heads for head to head bed arrangements.
* Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.
* Gas service outlets to be labelled and colour-coded with 3mm lettering.
* SANS 7396-1 should be used to specify the requirements from design to commissioning of medical gas and vacuum systems.
* Medical gas and vacuum pipelines shall be marked per SANS 7396-1 and ISO 5359, as applicable.
* Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.
* SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.
* Plain-ended copper tubing for low-pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.
* Laboratory gas taps and valves shall be marked as described in SANS 10140-4.

=== Lighting ===
Existing lighting systems may need to be modified to suit the clinical requirements in the facility. High bay lighting presents inadequate colour rendering quality for the accurate detection or easy diagnosis of certain clinical conditions. This needs to be evaluated in the selection of supplementary lighting systems.
*Lighting levels should be provided in line with the indoor lighting levels recommended in the Table 6 of IUSS Building Engineering Services .
*Mobile task lighting systems may be adopted in the serious and critical stay wards to supplement incorrect lighting quality.
*Emergency lighting and illuminated emergency egress signage should be linked to the back-up power system.
*External security lighting in external parking areas and spaces around the building should be enhanced to ensure the security of medical staff who need to change shifts at night.

=== Fire safety ===
A functional fire alarm system should be available to support the patient care setting. Fire is a very real threat due to the possibility of an oxygen-enriched atmosphere developing so ventilation is crucial.
The use of temporary facilities for medical care should note the following fire risks (NHS, 2020):
*Patients may have a very high dependency.
*Areas are not specifically designed for patients and do not meet guidance on fire compartmentation and progressive horizontal evacuation.
*Large numbers of patients supplied with oxygen up to 10 litres per minute.
*Possibility of oxygen concentrations exceeding those generally found in the atmosphere- less risk if effective ventilation or large volume i.e. high ceilings.
* Possibility of storage, in excess of 40 litres, of alcohol-based chemicals (such as hand-rub), necessitating a flammables cabinet on site.
*Staff who may not normally work together .
*Staff who may not be familiar with the area.
*Staff not trained in fire safety, progressive horizontal evacuation or oxygen isolation for the specific area.
These factors should be taken into account in fire risk assessments which should then address significant findings in an action plan. Fire assessments should be undertaken by a qualified person and shared with operations and building management staff within the facility. Measures developed should include:
*An automatic fire detection system
*An emergency egress plans are prepared that include patients who have a very high dependency.
*Signage, notices and lighting are installed and are working effectively.
*Management processes are in place to minimise the risk of fire from ignition sources, fuels and oxygen.
*Staff are trained and a fire safety guide sheet for staff is developed and issued.
*Emergency egress routes are kept clear.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Additional Resources''' ==
=== [[Directory of Service Providers|A Directory of Service Providers can be viewed here]] ===

=='''References'''==
<references />

[[Category:COVID-19| ]]
[[Category:Alternate Care Sites|Alternate Care Sites]]

----
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19|(Return to Top)]] 
----

Infrastructure Guidance for COVID-19/Alternate Care Sites

2020-05-08T08:44:15Z

Peta: /* Purpose and Approach */

[[Infrastructure Guidance for COVID-19|Return to Infrastructure Guidance for COVID-19]] 

== '''Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19'''==

This guidance work was initiated under the project titled: 
''Reducing Nosocomial and Community-Acquired Tuberculosis by Strengthening the Capacity of the South African Department of Health to Improve Implementation of Infection Control and Waste Management at All Levels of the Health System Under the President's Emergency Plan for AIDS Relief (PEPFAR)'' 

== '''Introduction''' ==
=== Purpose and approach ===
The global pandemic of COVID-19 caused by the coronavirus, SARS-CoV-2 is likely to result in a surge in need for medical care for Severe Acute Respiratory Syndrome (SARS) in South Africa. Considering the course of the pandemic in other countries, it is anticipated that South African hospitals will not have sufficient capacity to cope with the surge of persons requiring medical attention and that surge capacity via alternate care sites (ACS) will need to be established.
Surge capacity, contemplated here is not the frequent emergency department overcrowding experienced by healthcare facilities (e.g. Friday/Saturday night emergencies) or local casualty emergency that might overcrowd nearby facilities and have little to no impact on the overall healthcare delivery system. It is when a catastrophic event occurs and the affected population seek medical care from existing local healthcare facilities, causing healthcare infrastructure to become exhausted due to excess in demand. During a healthcare surge, the standard of care will shift from focusing on patient-based outcomes to population-based outcomes, and providers should anticipate “a shift to providing care and allocating scarce equipment, supplies and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals.”<ref>[https://asprtracie.hhs.gov/technical-resources/resource/491/altered-standards-of-care-in-mass-casualty-events Health Systems Research Inc., 2005]</ref> 

Surge capacity can be temporarily established in non-traditional environments, such as hotels, exhibition halls, community halls, and as field hospitals, on open spaces. 

In the context of this document, a quarantine site is a facility for patients who do not require continuous professional medical care, while an ACS is defined as a temporary facility that can provide continuous medical care for SARS. This document provides principles and considerations, high-level guidance for minimum requirements and examples for ACS. 

While an extensive set of health facility guidelines does exist<ref>[https://www.iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-servi IUSS Building Engineering Services (2017)]</ref>, these are applicable for conventional facilities and thus include services and guidelines that are not necessarily relevant to the treatment of a novel, highly infectious pathogen, with pandemic effects. Moreover, these do not provide well for the rapid and temporary establishment of facilities. 

In order to formulate high-level guidance, [[as invited by Business for South Africa]], the team reached out to professional industry bodies for inputs, in particular the South African Institute for Architects (SAIA), The Gauteng Institute for Architects (GiFA) [https://www.gifa.org.za/ Gauteng Institute for Architecture] and the [http://www.safhe.co.za/ South African Federation of Hospital Engineering (SAFHE)], by inviting input via a 36-hour research charrette. Relevant historical and contemporary literature was consulted, precedents identified and critically reviewed. An interaction with the team at Wuhan responsible for makeshift hospitals and emergency infectious diseases hospitals, Central-South Architectural Design Institute, was arranged with assistance of the Chinese Embassy. Material from the [[Infrastructure Unit System Support|Infrastructure Unit System Support (IUSS)]], international literature and guidance and input gathered from the broader architectural, engineering and healthcare professional communities was synthesised and moderated by the CSIR team. The draft was reviewed by an expert review panel. 
=== Acknowledgement of contribution ===
The contributions to the initial version of this were gratefully received. [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Acknowledgements|A list of these contributors can be viewed here.]]. 
New contributions are eagerly encouraged along with debate and discussion on the [[Talk:Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites|'''discussion forum.''']] tab above.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Scope and Assumptions''' ==
ACSs as discussed in this document are dedicated, temporary facilities for triage, testing, diagnosis, further referral and treatment of persons:
*suspected of having contracted SARS-CoV-2, (persons under investigation (PUIs)), who are symptomatic and/or are awaiting results,
*or are confirmed to be infected.
ACS will accommodate a variety of clinical, logistical, support and auxiliary services associated with the render of care. ACS will currently not be licensed to provide healthcare services. Since the ACS will operate in a non-healthcare facility, it cannot fully replace a hospital setting and its prime objective is to manage the patient load until the local healthcare system can meet demands. 

=== Exclusions ===
Quarantine facilities are accommodation facilities where a member of the community can remain for the duration of their isolation period. This is typically temporary housing for a cohort of people who do not need intensive medical attention but who cannot stay at home. Patients can take care of themselves and need limited monitoring by medical staff. Quarantine: Containing presumptive-case patients from each other and the general population.
Quarantine facilities – that is for asymptomatic persons who are in the community in self- or imposed isolation, but not displaying symptoms, or who are symptomatic, but are able to safely recover without clinical intervention and do not need continuous medical observation are not considered in this document.

=== Service regime ===
The following assumptions are made with respect to services under consideration.
* Temporary - limited to the part of the pandemic when the “conventional” hospital platform cannot meet demand. To be dismantled, thereafter.
* Uncomplicated, dedicated COVID-19 care is to be prioritised for ACS.
* Patients with comorbidities, paediatrics will be prioritised for conventional facilities, and only accommodated in ACS as a matter of last resort.
* 24 hour, 7 days a week operations. 

=== Assumed mechanism of transmission ===
Transmission of SARS-CoV-2 is understood to be from person to person firstly by [https://en.wikipedia.org/wiki/Transmission_(medicine)#Droplet_infection droplet] transmission, then by the [https://en.wikipedia.org/wiki/Transmission_(medicine)#Direct_contact contact] route and finally via airborne [https://en.wikipedia.org/wiki/Transmission_(medicine)#Airborne_airborne transmission] during or following mechanical aerosolisation. Water transmission risks are minor, occurring in special [https://en.wikipedia.org/wiki/Transmission_(medicine)#Fecal%E2%80%93oral Fecal-oral] circumstances. Reclassification of transmission mechanisms may nullify some of the approaches presented in this guidance. 

=== A call for strategic coordination ===
This document focusses on infrastructure requirements. These provisions are meaningless without staffing, equipping and resourcing. Whilst staffing, equipping and resourcing are not the focus of this document, these are likely to emerge as key constraining features. Resource constraints are likely to become acute during this pandemic. Doctors and nurses are already in critical short supply in South Africa and internationally, and are themselves susceptible to COVID-19 infection. Equipment and consumables are in short supply with heightened global demand, reduced manufacturing capacity and limits in trade flows. This necessitates strategic coordination, proactive planning, options appraisal and prioritisation. 

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Status Quo''' ==
=== Rationale and transmission status ===
According to the [https://en.wikipedia.org/wiki/World_Health_Organization World Health Organisation] (WHO), based on the largest cohort of COVID-19 patients, about 40% of patients with COVID-19 may have mild disease, where treatment is mostly symptomatic and does not require inpatient care. About 40% of patients have moderate disease that may require inpatient care; 15% of patients will have severe disease that requires oxygen therapy or other inpatient interventions, and about 5% have critical disease that requires the patient to receive mechanical ventilation. However, the evolution of the outbreak in some countries has shown a higher proportion of severe and critical cases and the need to rapidly increase surge capacity to prevent rapid exhaustion of biomedical supplies and staff. In some countries, doubling rates of cases every three days has been observed<ref>WHO-2019-nCoV-HCF_operations-2020, [https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf]</ref> 

South Africa has a high burden of disease, with a high prevalence of [https://en.wikipedia.org/wiki/HIV/AIDS_in_South_Africa HIV and TB]. Although evidence is yet to emerge of the effect of SARS-CoV-2 on a population with these pre-existing conditions, there is reason to proceed with caution<ref>The Conversation 2020, https://theconversation.com/tb-hiv-and-COVID-19-urgent-questions-as-three-epidemics-collide-134554</ref>. There is a potential direct and indirect benefit of ACS to people living with HIV and TB, as well as to general public health and the health system preservation. 

With the travel lockdown in place, and continued transmission, it appears that South Africa is on the cusp between cluster transmission and community transmission according to WHO’s classification, shown in the [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites#Key_clinical_and_infection_control_activities_for_different_transmission_scenarios_.5B3.5D|table below]], indicating that preparation should include temporary hospital facilities and mass critical care.

==== Key clinical and infection control activities for different transmission scenarios <ref>WHO 2020, [https://apps.who.int/iris/handle/10665/331492 https://apps.who.int/iris/handle/10665/331492]</ref> ====
{| class="wikitable"
|-
! !! '''No Case''' !! '''Sporadic Case''' !! '''Clusters of Cases''' !! '''Community Transmission'''
|-
| Faculty Space, Including for Transmission|| Usual Space. Enhanced Screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards). || More patient care areas re-purposed for COVID-19 within the health system, especially for severe cases || Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Staff|| Usual space. Enhanced screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards)||More patient care areas repurposed for COVID-19 within the health system, especially for severe cases||Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Supplies||
*On-hand supplies. Equip wards for COVID-19 treatment.
*Identify essential equipment and supplies, including oxygen.
*Prepare expanded local supply chain
||
*Expanded inventory of supplies with detailed protocols for use.
*Activate expanded local supply chain.
*Prepare national supply chain.
||
*Conservation, adaptation, selected re-use when safe.
*Activate contingency planning and procurement for essential equipment and supplies.
*National supply chain.
*Prepare expanded supply chain at the global level
||
*Activate contingency planning should critical equipment be in short supply.
*Determine allocation of lifesaving resources for HCWs and patients.
*Activate expanded global supply chain
|-
| Standard of Care|| Usual care with enhanced awareness and recognition of immediate needs for first COVID-19 patients|| Usual care and treatment for all patients, including those with COVID-19||Identify context-relevant core services. Shift service delivery platforms. Consider reduction in elective patient encounters, including elective surgical procedures.|| Mass critical care (e.g. open ICU for cohorted patients).
|-
| Care areas expansion|| No requirements for expansion|| Designate 10 beds per suspected COVID-19 case|| Expand COVID-19 patient care areas by a factor of 35 ||Expand COVID-19 patient care areas by a factor of 58
|}

=== Quantification of need ===
At this time there are various parallel initiatives aimed at forecasting the South African epidemic, quantifying the projected need for facilities, and a shortfall in existing capacity. At this time, there is no consensus on this. This section will be updated as further data becomes available.
ACS will prioritise mild to moderately affected COVID-19 patients where basic, targeted medical care will be provided. Should patients’ needs evolve, requiring escalation of care, then the transfer of patients from ACS sites to conventional sites of care will be needed as a matter of course, bringing with it logistical challenges and risks. In the event that the conventional hospital platform is unable to cope, ACS will have pressure to provide care for severe and critical patients, and finally for patients with comorbidity and special requirements, such as paediatrics, persons living with HIV (PLHIV), TB patients and pregnant women. The following pragmatic approach, aligned with the WHO recommended strategic approach, is suggested.
*ACS should preferably be identified with space for expansion.
*The set-up should be done so that levels of care can be upgraded to higher levels of uncomplicated care.
*A secondary upgrade for more diverse package of care may become necessary.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Strategic Approach''' ==
According to WHO, clinical interventions must be put into place immediately and then scaled up according to the epidemiologic profile.
[[File:COVID-19 Resource allocation.png|none|thumb|600px|right|WHO Strategic approach to clinical care]] 
Under this declared state of disaster, the clinical care strategy which cannot be accommodated within existing facilities, can, on a temporary basis be hosted in ACS:
*Within and around existing healthcare facilities, via reconfiguration and/or augmentation.
*In existing non-healthcare buildings suitable for repurposing, such as universities, hotels and conference centres, warehouses, gyms, hostels etc.
*On open fields, including paved parking areas with rapidly constructed, dismountable structures, such as modular tented structures or using rapid modular construction techniques. 

ACS will provide isolation, general (non-acute) care for patients with mild to moderate symptoms and as required, acute care for patients with severe symptoms. Containing confirmed-case patients from general population. Confirmed-case patients can be housed together en masse, while presumptive-case patients must be individually quarantined.
As shown in the WHO Strategic approach to clinical care, the WHO recommends a range of services to meet patient need (''Citation needed''). General (non-acute) care ACS model is designed for minimal acuity patients requiring minimal activities of daily living support (e.g. COVID-positive with minimal symptoms or require <2L of oxygen). Acute care ACS model is designed for higher acuity patients requiring closer monitoring or respiratory support (e.g. COVID-positive with pneumonia or respiratory distress requiring ventilator support). Paediatric patients are to be accommodated in separate wards, where strictly controlled visitation may be allowed. 
As a preliminary estimate, the following ratios of service is proposed:
[[File:COVID Ratios of Service.png|none|thumb|600px|center|COVID Ratios of Service]]

{| class="wikitable"
|-
! '''Case severity, risk factors<ref group="Notes"> Test suspect COVID-19 cases according to diagnostic strategy</ref><ref group="Note"> Known risk factors for severe COVID-19: age over 60 years, hypertension, diabetes, cardiovascular disease, chronic respiratory disease, immunocompromising conditions.</ref>''' !! '''Recommendations'''
|-
|Mild || Patient should be instructed to self-isolate and contact COVID-19 information line for advice on testing
and referral.
|-
|Moderate, with no risk factors ||Test suspected COVID-19 cases according to diagnostic strategy. Isolation/ cohorting in:
* Health facilities, if resources allow;
* Community facilities (e.g. stadiums, gymnasiums, hotels) with access to rapid health advice
(i.e. adjacent COVID-19 designated health post/EMT-type 1, telemedicine)
*Self-isolation at home according to National guidance
|-
| Moderate, with risk factors || Patient should be instructed to self-isolate and call COVID-19 hotline for emergency referral as soon as possible
|-
|Severe || Hospitalization for isolation (or cohorting) and inpatient treatment.
|-
|Critical|| Hospitalization for isolation (or cohorting) and inpatient treatment.
|}

=== Notes and References: ===

<references group = "Note" />
<references />

=== Typology dictates & case studies ===

[[File:NHS Nightingale Hospital London.png|thumb|NHS Nightingale Hospital London <ref name="NHS Nightingale Hospital London">Coronavirus: Building NHS Nightingale Hospital London, 2020 [https://www.bbc.com/news/in-pictures-52092253 https://www.bbc.com/news]</ref>, ]]
To meet the requirements set out in this guidance, prospective “host” sites should be carefully evaluated. The type of “host” site selected will strongly influence or dictate the choice of ACS service model.

No site is likely to meet all requirements and recommendations set out in this document. Adaptations and compromises will be necessary. Services should be provided on site where it is pragmatic to do so, for example where similar services are provided. Outsourcing can also be practical/feasible for some services, such as laboratory services, catering and laundry, provided suitable logistical arrangements can be made.

Some typological responses and service models are set out in precedent examples, shown below. The examples demonstrate that a variety of host settings are workable, provided that the appropriate utility can be contrived.

=== Pragmatic approach ===
Other than in metropolitan areas, co-location of ACS on the premises of, or adjacent to existing healthcare facilities will often be preferable because this is where intensivists and specialist clinical staffing will be available, and support services may be well established. Nevertheless, augmenting capacity at existing facilities should take into account current workloads and capacity to ensure that the COVID-19 surge disrupts normal service provision as little as possible, including continuity of care for patients with chronic conditions and TB and HIV patients. 

*'''[[Infrastructure Guidance for COVID-19/Alternate Care Sites/Case Studies|SARS ACS Precedents and Case Studies can be found here]] '''

=== Notes and References ===
<references />

== '''ACS Infrastructure Planning''' ==

=== Establishing a team ===
A planning team should be formalised to establish the minimum planning and operational requirements for the ACS and to liaise with the local community. The team should include individuals with expertise in the following areas (ideally with knowledge of healthcare delivery under emergency conditions):
*Disaster response / emergency management coordination,
*Clinical care and staffing,
*Infection Prevention and Control practitioners must be involved in all stages of planning, commissioning, in-use, and decommissioning of the facility
*Facility set-up, operations and management,
*Security,
*Transport (patient, staff),
*Engineering and project management,
*Procurement and coordination of supplies, equipment and pharmaceuticals, and
*Community liaison to ensure that concerns of the adjacent population on understood an addressed.
It is important to ensure compliance with health, safety and building regulations, by ensuring the involvement of relevant local authorities. Stakeholder engagement should be formally documented. Concerns and grievances should be systematically addressed.

=== Structural integrity and operational responsibility ===

'''Structural modifications:''' ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered. 

'''Competent person:''' All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed. 

'''Asset responsibility:''' Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented. 

'''Integrity and responsibility'''

'''Structural modifications''': ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered.

'''Competent person''': All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed.

'''Asset responsibility''': Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented.

'''Decommissioning''': Decommissioning of the facility shall be assigned to the competent person discussed above. All residual structures upon decommissioning shall comply with the National Building Regulations. Upon decommissioning, removal of equipment shall be the responsibility of the owner. An infection prevention and control practitioner should be engaged in the decommissioning phase to oversee terminal cleaning and disinfection of equipment and premises.

'''Closure''': Once all patients can be safely discharged or transported back to existing facilities for continued care and there are no ongoing healthcare surge capacity needs, the ACS can be closed. Shut down of an ACS will require decommissioning, identification of new homes or storage for equipment, and termination of ongoing contracts or arrangements. Shut down should be expedited so that the facility can quickly be returned to the control of the existing owners and returned to its usual function.

Action checklist items for ACS closure should include, but not be limited to, the following:
*conduct a site walk-through with the facility owner when shutdown activities are completed to ensure that terminal cleaning and disinfection of supplies and premises, removal of equipment and supplies, and other surge closure activities have been completed to the owner’s satisfaction.
*perform medical records storage procedures.

== '''Site Selection''' ==
When selecting a site, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital can be utilised to determine whether the site is suitable for a 100, 1000 or 2000 bed facility, as required. The following indicative minimum site sizes are needed:
*100 Bed ACS/ hospital conversion, requires ± 4 300 m2
*1000 Bed ACS/ hospital conversion, requires ± 17 600 m2
Evaluation should be done by examining plans (if available), satellite images, drone images, scans and by physical inspection (walkabout). A comprehensive photographic survey should be undertaken and retained for record purposes on the site inspection. This will serve as an audit record and may assist in returning the site to its original function on ACS decommissioning and closure. When scrutinising documents and conducting site inspections to confirm the suitability of a site to host an ACS, the following criteria should be taken into account.
=== Criteria ===
*Affordability (costs, including operational costs known and budget identified),
*Sufficient physical space and capacity to house the immediate need, with the potential to accommodate physical space requirements. For example, open site should not be sloping,
*Legal rights and encumbrances, including renewal opportunity,
*Good access to highway and main roads,
*Well secured perimeter and limited controlled access points,
*Proximity to other hospitals and care sites,
*Accessibility for key staff and public transport,
*Good vehicular access around the site to set up temporary equipment such as back-up generators,
*Free from clear and present danger,
*Outside attenuation zones, floodplains,
*Outside high wind zones,
*Structure in good repair,
*Effective onsite facilities management team who understand how systems work,
*Potential for expansion, if required,
*Access to sufficient capacity for
**potable water,
**adequate sewage,
**telephone,
**internet access with sufficient bandwidth,
**electricity,
*A zone for cleaning, disinfection, and decontamination of equipment at least 15 metres away from occupied areas with access to water, a hard impervious surface and drying areas in the sun, with runoff discharge into the sewer and not into marine ecosystems or the environment. Include area for cleaning and storage of cleaning equipment.
*Likelihood of acceptance of hosting an ACS by the adjacent and local community

=== Desirable ===
*Durable, cleanable surfaces,
*Large open spaces that can be converted to accommodate temporary structures,
*Good ventilation,
*On-site kitchen and laundry,
*Housekeeping staff (chemical and equipment storage, lockers, rest facility, administration office),
*Space conducive for staff respite area and locker rooms,
*Amenities with universal access,
*Fire protection safety and equipment,
*Elevator access for patients if the building has more than one floor,
*Capacity for expansion, and
*Accessible to at least two roadways to provide continued access in the event that one roadway becomes blocked on inaccessible.

== '''Infection Prevention and Control''' ==
General guidance for COVID-19 [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|Infection Prevention and Control]] can be accessed [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|here]] 

Infection prevention and control in the context of COVID-19 should respond to transmission routes of primary concern for the pathogen of interest (droplet and contact transmission, and management of risk waste) as well as infection risk of a general nature (water and sewerage, airborne transmission – under high TB/HIV burden, and general waste).
In addition to satisfying [https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html standard precautions for all patient care], transmission-based precautions should focus on three pillars: exposure reduction by spatial configuration, operational strategies, and personal protection.
=== Transmission-based precautions ===
'''Droplet and contact spread''': Transmission of SARS-CoV-2 virus occurs via droplet and contact spread. The virus has been shown to persist on surfaces for extended periods of time and is known to be efficient at infecting people. 

'''Medical waste and linen:''' As SARS-CoV-02 is carried in body fluids and faecal matter, disposal of contaminated items (tissues) and cleaning regimes (spaces, garments, linen) should be accommodated carefully in the workflow design and infrastructure provision. A site-specific waste management plan should be formulated in accordance with a site-specific waste management plan with reference to SANS 10248. 

'''Airborne transmission:''' Under exceptional circumstances, the risk of airborne transmission arises for SARS-CoV-2, as detailed below.
{| class="wikitable"
|-
!Airborne Transmission Risk Factors
|-
|
As SARS-CoV-2 is not considered airborne, respiratory protection against airborne transmission is not considered necessary, except where aerosolisation of particles may be a risk.
According to the CDC
*tracheal intubation,
*non-invasive ventilation,
*tracheotomy,
*cardiopulmonary resuscitation, or
*manual ventilation before intubation and bronchoscopy.
According to doctors in the field also when performing
*COVID-19 diagnostic sampling as patients can be induced to cough and sneeze.
*Suspected or confirmed comorbidity of TB is not an additional risk where correct COVID-19 PPE is applied.

|}
South Africa has a high prevalence of TB and HIV, and therefore, although the risk of COVID-19 transmission via the airborne route is not paramount, there is a high likelihood that undiagnosed TB infectious patients may present at the ACS for treatment. TB triage may be challenging in the ACS as there are symptoms in common (coughing) with COVID-19. This country-specific risk is taken into account in this guidance

=== Additional precautions ===
'''Water and sewerage contamination:''' The International Water Association [[Infrastructure Guidance for COVID-19/Alternate Care Sites/COVID-19 A Water Professionals Perspective|concluded]] that water and sewerage contamination is not considered to be a key risk factor for COVID-19. The panel expressed concern for “how waste and specifically wastewater (medical) would be handled by places (e.g., hostels, hotels) that are used to serve as interim COVID-19 quarantine or testing facilities or accommodation ([ACS]. These are places other than hospitals that are used in the interim for such purposes and do not usually handle wastewater from medical settings. Such facilities should be monitored carefully.” 

== '''Spatial strategies for infection prevention and control''' ==

=== Restricted access and zone control ===
The site will be arranged to establish clear zoning, with a clear restricted zone protocol and access protection. Zones should be deemed to be "contaminated" or "uncontaminated" with clear transition areas between them.

; Contaminated zones
: (also known as "dirty areas") are areas occupied by COVID-19 infected persons, PUIs, equipment, materials and supplies which have come into contact with such persons without yet undergoing a decontamination procedure. These areas will include patient ward areas and ablutions, patient admissions (including ambulance drop-off) and the associated clinical areas. Staff rest and dining facilities should be outside the contaminated zone. Limited stock for immediate use should be kept in the contaminated zone. Layout designs should consolidate contaminated zones as far as reasonable, and avoid uncontaminated zones as islands in contaminated zones.

; Uncontaminated zones
: (also known as "clean areas") are areas not generally occupied by PUIs or confirmed COVID-19 infected persons. Equipment, materials and supplies in these areas have not yet come into contact with contaminated zones or have undergone a decontamination procedure. These will include clinical management planning rooms, stock rooms, bulk stores, pharmacy, laboratory areas, kitchen and laundry.

; Transition zones
: (also known as intermediate zone) are the spaces through which transfer of people and goods from uncontaminated to decontaminated zones, and vice versa, occur. Materials from the contaminated zone should be decontaminated or contained in the transition zone. The transfer of goods and persons should be highly ritualised and, as far as possible, traffic across transition zones should be minimised. Transition areas should be strategically located to serve this function. Separation of in-going and out-going transfer of goods and persons is preferable. Transition areas include ambulance, trolley decontamination, CSSD, laundry and waste bagging areas, patient locker area and staff change areas with spaces for donning and doffing of PPE.

=== Site layout and master-planning ===
Spatial configuration and layout can ensure unnecessary cross-over of function is avoided. This entails the systematic separation of functions and the managed transition between activities to facilitate consistency of care, an orderly, efficient work environment, less waste and reduced risk for improved outcomes. To achieve this, functional relationships should first be considered at the site level before being considered at the building level. 

<gallery mode=packed heights=300px style="text-align:left">
Layout for a SARS facility, clustering functions with minimised cross-over.png|center|thumb|Layout for a SARS facility, clustering functions with minimised cross-over <ref name="Layout1">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Layout_for_a_Patient_cohorting_strategy.png|center|thumb|Layout for a Patient cohorting strategy <ref name="Layout3">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Tygerberg Hospital virus triage unit site layout.png|center|thumb|Tygerberg Hospital virus triage unit site layout <ref name="Western Cape Provincial Government, 2020a">Western Cape Provincial Government, 2020 a</ref>
</gallery>

The WHO's Clustering Layout <ref name="Layout1"/> and Tygerberg Hospital virus triage unit<ref name="Western Cape Provincial Government, 2020a"/> show worked examples of building and site layouts, which are configured with these principles, respectively. '''Cohorting''' is defined as clustering patients with similar or compatible clinical needs together for risk reduction, acuity, efficiency and quality management, as illustrated in WHO's Cohorting Layout <ref name="Layout3"/>

=== Workflow ===
Within individual functional zones, the workflow activities can be arranged to proceed from clean procedures to contaminated procedures. In the example below, the staff arrival, PPE donning, doffing and patient flows are worked to have controlled interaction and minimised cross-over

<gallery mode=packed heights=400px >
ACS HCW Flow.png |ACS Health Care Worker Flow
COVID-19 Workflow in small unit.png |COVID-19 Workflow in Small Testing Unit <ref name="Western Cape Provincial Government, 2020b>Western Cape Provincial Government, 2020 b</ref>
COVID-19 Workflow in large unit.png |COVID-19 Workflow in Large Testing Unit <ref name="Western Cape Provincial Government, 2020b"/>
</gallery>

As far as possible, a single direction flow of clean to dirty is recommended for all processes: support services, supply and waste.
The Small ACS unit workflow diagram<ref name="Western Cape Provincial Government, 2020b"/> illustrates the recommended separation of access and exit, separate waiting seats, for persons who may be COVID-19 infected. Separate spaces are provided for donning and doffing PPE. Staff change areas are provided.

In the Large ACS unit workflow diagram <ref name="Western Cape Provincial Government, 2020b"/>, there is a clear separation between staff areas and patient areas. Waiting seats are set far apart to reduce transmission risk. Staff change rooms are provided near the point of entry to the facility for staff to change from street clothes into medical work clothes. To prevent work clothes worn inside the facility from contaminating street clothes, these are kept in separate lockers. A step-over barrier from dirty to clean sides of the change room is helpful to enforce a mind-set of avoiding cross-contamination. Bins for contaminated garments are to be provided in change rooms. Shower facilities are to be provided for staff.

== '''Operational Strategies''' ==
=== Cleaning, disinfection and decontamination ===
Surface and substrate specification, and detailing of all areas should, as far as possible, allow for frequent:
*Cleaning with detergent and water.
*Disinfection with 75% alcohol solution (metal surfaces).
*[https://en.wikipedia.org/wiki/Sodium_hypochlorite Sodium hypochlorite] (1,000 ppm)/ Household bleach.
*Disinfectants listed on the EPA List N<ref>The United States Environmental Protection Agency, [https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 List N: Disinfectants for Use Against SARS-CoV-2 (Last Visited 2020) ]</ref> (for non-critical environmental cleaning).
*High-intensity ultraviolet surface disinfection (UV-C).
*Decontamination and sterilisation of clinical equipment.

=== Goods and waste management ===
Remove any unnecessary furniture, equipment and paraphernalia from all patient care and clinical areas. Provide a clear, secure space for waste management. Any potentially infectious waste materials generated at the ACS should be considered and treated as medical waste (health care risk waste). The applicable legislation is:
*[https://www.gov.za/sites/default/files/gcis_document/201409/35405gen452.pdf The National and Provincial Health Care Risk Waste Management Regulations].
*[https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf National Department of Health COVID-19 Environmental Health Guidelines.]<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>
Waste disposal bins should be positioned near the exit inside each patient rooms or wards to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another patient in the same room.

=== Materials and finishes ===
Floor materials must be:
*Level,
*Free of dust and oil,
*Impervious and smooth,
*Slip-resistant in wet areas (e.g. patient ablutions).
Smooth, cement screed floors are acceptable. Where hosting facilities have carpeted areas, a risk assessment of factors such as durability, hygiene and decontamination needs to be conducted. In cases where the acceptance of carpeted flooring is contradicted (but other factors make it a compelling option), temporary floor finishes or covering can be investigated.

== '''Personal protection''' ==
=== Hand sanitation ===
Where wash-hand basins are not provided, clinical wash-hand basins should be installed, at the minimum rate of provision of one wash-hand basin per 5 beds. Clinical wash-hand basins (see figure below) have a variety of features not present in standard wash-hand basins, which are preferable for infection prevention and control. Where standard wash-hand basins are provided, an upgrade is not necessary. In all cases, there should be no surfaces and no clutter, equipment or supplies in the vicinity of wash-hand basins, including surgical gloves.
<gallery mode=packed heights=400px>
Clinical hand wash basin.png|Handwash Basin <ref>de Jager 2020</ref>
Portable Wash-hand Basin.png|Portable wash hand basins can be provided in ACS <ref name="BDPa">BDP 2020, NHS nightingale instruction manual, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf</ref>
</gallery>

Where wash-hand basins are not available, portable units can be used, as shown above<ref name="BDPa"/>. Mounted brackets for hand sanitisers are to be provided for every two beds, preferably mounted near the foot rather than the head of the bed and at all common touch points such as entry points at ablution facilities, linen room, sluice, storerooms, medicine rooms/cupboards, near refrigerators, telephones, light switches, at entry/exit doors, etc.

=== Personal protective equipment ===
Donning and doffing points for personal protective equipment, and convenient, safe disposal of consumables to be placed at critical key points when entering patient areas.
----

== '''General transmission mitigation''' ==
=== Water and sanitation ===
To comply with National Building Regulations; Hazardous Biological Agents Regulations and National Department of Health COVID-19 Environmental Health Guidelines<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>.

=== Droplet aerosolisation ===
When designating areas for procedures during which aerosolization and airborne transmission risk is high, the building ventilation must be carefully considered to take into account downstream risks. In particular, consider to where potentially contaminated air, arising from aerosol-generating procedures, is exhausted. In general, air exhausted directly to the outside is diluted and considered safe, unless there are openings to occupied spaces near the exhaust air outlet. 

In the event that potentially occupied spaces will receive partially diluted or undiluted contaminated air, or where this is indeterminate, the aerosolising activity should be designated to an alternate area. In the event that an alternative is not available, some treatment regime (air filtration or air disinfection) is necessary. 

In most naturally ventilated settings, the airflow direction between zones may fluctuate according to the wind direction. Such high-risk spaces should not be adjacent to spaces with high susceptibility rates, such as PUI areas and uncontaminated areas. Contaminated areas should not be directly adjacent to clean areas unless mechanically ventilated. 
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|Guidance on COVID-19 building ventilation design is provided here]].

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Health, Safety and Well-being''' ==
In addition to the infection prevention and control measures discussed above, the following should be provided for health, safety and well-being.
=== General provisions ===
*Minimised and controlled entry and exit points, with suitable control.
*Clearly identified accessible and marked routes for patients, staff, goods and waste.
*Clear designation of restricted zones.
=== Site level provisions ===
*Safe staff parking and arrival of staff via planned and public transport.
*Clearly demarcated parking for people with disabilities.
*Arrival and departure point for patients via public transport, passenger vehicles, and emergency service.
*Limited safe patient parking.
*Supply of goods and removal of waste.

=== Within and between buildings ===
*Entrances with a clear opening width (CoW) of at least 900mm.
*Routes with a minimum width of 2 000mm free of hazards, for example, rubbish bins.
*All clinical, patient and support areas to be accessible by trolley.
'''Ramps''' should be of stable construction, capable of sustaining a mass of 300kg. They should incorporate side lips and the surface should be slip-resistant. Gradients should be as gentle as the circumstances allow. (Recommended maximum 1:20). 
'''Small changes in floor levels''' are not desirable, but where these exist are to be clearly marked with reflective paint/ tape, and lit at night
Elevators between different floors, where patients need access (The recommended minimum lift size for patient trolley/stretcher movement is 1 400mm × 2 400mm, however, this may not be possible). 
'''Pathways''' to be lit at night, where used at night. 
'''Staircases''' must be well-lit at night with non-slip surfaces and secure balustrades. 
'''Doors''', Double doors and automated or push-operated doors to all clinical areas are to be preferred, where these are newly installed or able to be retrofitted. Door closers are to be disabled, where not necessary to reduce touch surfaces. Hand sanitisers to be provided at where high touch common surfaces occur (e.g. wall-mounted at doorways).

=== Signage ===
The appropriate level of information to facilitate legibility, orientation and wayfinding. Minimum standards, signage to be:
*Clearly visible, simple font, font size, contrasting colours, placed in the field of vision
*Washable
*Comprehensive safety signage - fire signage (exits, equipment etc.)
*Restricted areas clearly marked
*Identification signage - each patient space to be allocated a unique number and a whiteboard or perspex sheet for writing the patient’s name
Signs should be posted immediately outside of patient rooms indicating appropriate IPC precautions and required personal protective equipment (PPE).
Signage of a temporary nature can be provided on laminated white A4 sheets attached eye-level. The text should be black sans-serif (for instance Arial) text at least 40point size and centrally positioned on the sheet. Detailed guidance on signage is provided in IUSS Inclusive environments.
=== Safety and security ===
Upon identification of the ACS host site, a team should be convened to conduct a multidisciplinary safety and security analysis. These critical team members need to form the working committee responsible for undertaking the detailed assessment of the existing facility’s security. They should analyse data about the security system’s condition and review existing security concerns or issues that are reasonably likely to become concerns in the near future. The figure below represents a five-zone approach to security, which is a recommended, systematic approach to security.
[[File:Zonal approach to security.png|center|600px|thumb|IUSS Security- Zonal Approach to Security <ref name="IUSS Security">IUSS Hospital design principles - Security [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file]</ref>]]
The security strategy should take into account that whilst clinical services and some logistical and support services will be required 24 hours a day, seven days per week, some support services, logistics services and auxiliary services may only be operational for the minimum periods required to meet demand. These functional elements should be capable of being secured, for example over weekends and at night, as the case may be.
Detailed guidance is available in [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file IUSS Hospital design principles - Security] <ref name="IUSS Security"/>

=== Comfort and dignity ===
Supplemental heating: Patient health and comfort are dependent on, amongst others, maintaining body temperature. The ACS structural technology must be selected to achieve the general indoor environment conditions discussed in a subsequent section for all clinical and occupied areas. As we are moving into South African winter supplemental heating may be required, especially in the evenings, in order to avoid hypothermia. Use of fans, bar, radiator or gas heaters should be prohibited. Unless clinical areas can be maintained above 18 degrees centigrade, patients should each have an infrared heater available, in addition to blankets. Personal/ donated blankets can be considered if they are laundered first and could be destroyed upon discharge.
Mobile screens should be available to provide privacy where necessary (e.g. during consultations or procedures).
<gallery mode = packed heights = 400px>
Bed_Isolator_-Vietnam.png|thumb|Flexible Barrier Isolator<ref>WHO. (2020), Severe Acute Respiratory Infections Treatment Centre. Geneva, Switzerland : WHO- World Health Organization</ref>
ACS Cohort beds.png|ACS Cohort beds.png|thumb|Excel Centre London 04-2020 <ref>Architects' Journal 2020, [https://www.architectsjournal.co.uk/news/nhs-nightingale-bdp-on-the-first-nine-days-converting-the-excel-centre/10046749.article https://www.architectsjournal.co.uk/news]</ref>
</gallery>
Some solutions which address patient privacy and dignity are depicted above.

=== Notes ===
<references/>

== '''Schedule of Accommodation''' ==
Based on clinical needs of the ACS, a schedule of accommodation can be crafted capturing the clinical, clinical, logistical, support and auxiliary services associated with the render of care. When deriving a schedule of accommodation, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital tool can be used. Functions to be accommodated are: 
'''Clinical services''': Triage, rapid assessment of persons entering the facility, to expeditiously identify and render the appropriate service. Admissions and registration. Inpatient accommodation is to be organised according to cohorting principles, discussed above. Testing and diagnostics, including laboratories and x-ray. Safe storage and dispensing of drugs to patients.Offices for clinical administration and clinical planning meeting rooms in the clean zone are needed. 
'''Logistical services:''' Logistical services will entail management of flows of people, goods, services and information to and from the site, as well as within the site. It includes security and communication arrangements. Staff entry, preparations to transition from outside to clinical work environment, including pause areas for relief. Emergency services, visitors. Goods, supplies and storage and waste removal and/ or treatment.
Support services key to the provision of clinical services should be separated so that the risks associated with that particular activity can be managed. 
'''Support services are:'''
*Laboratory services
*Catering
*Laundry
*Environmental cleaning and housekeeping
*CSSD
*Maintenance and cleaning of surrounds, eg. waste areas
*Porters/”runners”, stretchers/wheelchairs
*Mortuary
* Security
Support services can be provided off-site, in which case, safe, secure and efficient transfer and logistical arrangements should be designed. 
'''Auxiliary services:''' Auxiliary services are services which may be provided on or near the ACS site, but which are not directly related to core clinical care. This included overnight accommodation for staff who may not wish to return home to avoid exposing their families, or who need rest between shifts, or for discharged patients awaiting transport home, volunteers who have recovered from SARS-CoV-2.
Limited psychosocial services and allied health services may also be provided on or near ACS for example by approved partners.
Examples of schedules of accommodation for patient and support spaces for a protective isolation ward is available [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedule for COVID-19 Isolation Wards|here]] and mild to severe cases [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedules for COVID-19 Wards for Mild to Severe Cases|here]].

== '''Clinical Services''' ==
=== Triage ===
Confirmed COVID-19 cases and PUIs who are referred from a testing facility or a higher level of care, will enter the facility in a triage area to receive vital screening and initial assessment. They will be registered and admitted to inpatient care. They will be assigned a "ward" or section of the facility - based on disease status and acuity. These are Protective Isolation, the Mild & Moderate ward, or the Critical & Severe wards. Patients should be clustered according to gender. As far as practicable, ablutions for each gender, isolation patients, paediatrics and staff shall be separately provided. Paediatrics patients, if admitted, are to be assigned a dedicated section.
As patients recover or deteriorate, they may be relocated to the appropriate section/ ward.
Once the patient has sufficiently recovered and a negative test result is received they will be appropriately decontaminated and discharged, collecting medication from the dispensary on exit. Patient movement between various sections of the ACS will be restricted as far as possible, with mobile radiology units, in-ward medication dispensing and in-ward food service.

=== Inpatient ACS accommodation ===
Separate spaces for:
*suspected, unconfirmed cases, under observation (PUIs), to be accommodated in isolation facilities (separate rooms, if possible);
*patients with confirmed COVID-19 with mild to moderate disease, not requiring dedicated oxygen therapy;
*patients who require dedicated oxygen therapy;
*patients requiring mechanical ventilation; and
*recovered/ confirmed negative.
==== Protective Isolation Facilities ====
Suspected, unconfirmed cases, under observation – persons under investigation (PUIs) to be accommodated in protective isolation facilities (separate positive-pressure rooms, if possible). PUI are restricted to their rooms. All food and laundry services will be brought to the PUI rooms to reduce interaction and potential contamination. All waste will be collected by facility staff and taken to waste handling areas. Infection prevention and control measures are put in place for the handling of used food utensil and laundry as well as waste collection. PUI areas will have restricted access, including for staff serving other inpatient sections, for confirmed cases.

==== Inpatients accommodation for confirmed COVID-19 ====

Inpatient facilities confirmed positive COVID-19 can be accommodated in large shared ‘wards’ with partitioning between patients. Partitioning between patients is optional. Partitioning is preferable to curtains found in conventional hospitals, as they are more conducive to daily cleaning. If curtains are used, antimicrobial treated fabrics with biocide used to treat the curtains has been tested to international standard EN 14476 and shown to be effective against H1N1 Influenza A Virus (Swine Flu), >99.999% kill rate in 5 minutes and measles morbillivirus, >99.99% kill rate in 5 minutes are preferred. If only separate rooms are available, patient monitoring and surveillance will need to be accommodated. This phase of treatment has a lower area/space requirement compared with PUIs, as cross-infection between patients is less of a concern. Shared ablution facilities are acceptable. It is recommended that, at least, two general accommodation ward areas be provided. 

a) Mild and moderate patients, and 
b) Serious and critical patients. 

The room must have openable windows for natural ventilation if a dedicated positive pressure ventilation system is not available. Ducted ventilation systems shall not be shared between PUI areas and confirmed COVID-19 patient areas. 
[[File:COVID-19 ACS - protective isolation – bed layout.png|thumb|center|800px|ACS - protective isolation – bed layout]]
[[File:COVID-19 ACS – mild-moderate patient bed layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient bed layout]]
[[File:COVID-19 ACS – mild-moderate patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient shared ward layout]]
[[File:COVID-19 ACS – severe-critical patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – severe-critical patient shared ward layout]]

Examples above show bed layout with bed spacing for protective isolation, a mild/moderate patient and a mild/moderate patient shared ward and for a severe/critical patient

=== Patient services ===
Patients in ACS will not generally be ambulatory and will be confined to their room, or cubicle in a bed. In general, domestic beds or hospitality industry (hotel) beds are not suitable for patient care. These should only be used where a hospital-grade bed cannot be sourced, as hospital beds are designed for ease of cleaning and decontamination (for infection prevention and control) and with patient and ergonomics, safety and comfort taken into account (they prevent back injury for nursing staff and can help to prevent bedsores). The higher the specification of bed, the more suitable it is for the higher levels of care. Lockers for patients personal belongings should be provided in the uncontaminated zone (in which case bedside lockers will not be necessary), and it is preferable (where bedside lockers are not provided) for overbed tables to be provided, per bed, if possible. 
The following beds are suitable:
*Repaired and refurbished beds from condemned hospital stocks.
*South African National Standard, SANS 521:2013 Edition 3.5, on Hospital beds and cots ISBN 978-0-626-28830-3.
*Beds listed on the National Treasury (See [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Hospital Bed Specification|specification]]).
The table below details the minimum services required at each patient bed. Details on these services are discussed in a subsequent section of the document.

{| class="wikitable"
|-
! Service/ Capacity!!Triage!!Isolation !!Mild – moderate inpatient!!Severe case wards!!Critical case wards
|-
| Power – 16A 230V Single socket outlet||As needed ||1 per bed||1 per bed||3 per bed||6 per bed
|-
| UPS Power – 16A 230V Single socket outlet ||As needed||1 per bed||1 per bed||1 per bed||2 per bed
|-
| Medical Air<ref group="Note">Mobile units recommended for intermittent use. 3 per 20 beds</ref><ref group="Note">There are some ventilators which have built-in compressors allowing them to function without Medical Air. This is however, not the norm. With Ventilators probably being the most difficult medical device to obtain at present, it would be prudent to rather allow for Medical Air at each bed.</ref> (LP)400kPa||No||Yes||No||Yes||Yes
|-
| Medical O2 -400kPa||Portable/shared||Portable/shared||No||One||Two
|-
| Vacuum-40kPa||No||Portable/shared||Portable/shared||Yes||Yes
|-
| Equipment rail||||||||Yes||Yes
|-
| Upper room UVGI||Optional||Optional||||||Optional
|-
| Examination light||No||No||Yes||Yes||Yes
|-
| Room Ventilation rate||60 L/s per person||10 L/s per person||10 L/s per person||10 L/s per person||12 ACH
|}
'''Notes: '''
<references group="Note" />

Two additional 16A 230V single socket outlets, one two-pin outlet and a worktop should be provided for every 32 beds (or part thereof), for:
*Electrocardiograph (ECG): Could be omitted if monitors have a full 12 lead ECG function.
*Blood gas analyser: Could be omitted if a Lab Services are available.
*Staff cellphone charging.

Example of healthcare technology to be provided for critical care patients is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]. Severe patients may be provided continuous positive airway pressure (CPAP). Emergency trolleys (“crash carts”) are to be provided in patient areas with convenient access to patient beds, out of the passage of corridors and is moved to the patient when needed. 1 crash cart for every 16 patients (or part thereof, with at least one dedicated for PUIs. An example of provisions for a crash cart is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]
==== Patient ablutions ====
[[SARS-CoV-2 is found in faecal matter]], so careful management of patient body fluids is crucial and convenient, practical support for frequent cleaning of ablutions especially shared ablutions is necessary. Dedicated ablutions (toilets and showers) are to be provided for patient use. Toilets and showers should be in separate rooms.
Hand washbasins and or/ hand sanitiser should be provided both inside and outside the toilet room so that patients can wash their hands on the way in and on the way out of the room.
*1 toilet for every 8 persons.
*1 shower for every 8 persons.
*1 disabled ablution for every 8 regular ablutions (or part thereof).
*1 disabled shower for every 8 persons (or part thereof).

Critical and severe patients may be sedated and have a reduced need to access ablutions, ablution facilities proximity and provision can take this factor into account. Showers and wash hand basins should have hot and cold running water. Where possible ablution facilities must have openable windows for natural ventilation, if not possible the bathroom extraction and room ventilation system must be reviewed before admitting patient '''(see [[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|ventilation]]).'''

Portable toilets and showers may be used, provided that suitable hand wash facilities are provided. These will need to be suitably located, preferably in decentralised clusters, so that patients can easily access them without needing to walk very far. Ablutions should be located and designed in such a way as to provide visual and acoustic privacy, dignity and avoid disturbance of other nearby patients when accessing, using or cleaning the ablutions. Separate ablutions are to be provided for PUIs and confirmed patients.

====Makeshift sluice areas ====
In conventional hospital settings, sluice rooms are provided for cleaning and sanitation of soiled equipment, such as bedpans. In a temporary setting, such as an ACS, the establishment of a temporary sluice room may not be practicable, and there may not be facilities for emptying buckets, rinsing equipment etc.. The following is suggested:
Allocate a toilet, hand wash basin, not in splash range and restrict access to it for draining buckets and install a macerator for disposal of disposable bedpans. Electrical, water and waste supply points required as per supplier specification.
==== Dedicated patient treatment areas ====
The following dedicated, private spaces per ward for clinical procedures are recommended:
*Counselling and consulting room (can be shared), as shown in the figure below
[[File:Consulting room example layout.png|400px|thumb|center|Consulting room example layout]]
*Minor procedures room, as per the example provided in the figure below 
[[File:Treatment-minor procedures room example layout.png|400px|thumb|center|Treatment / minor procedures room example layout]]

== '''Logistical Services''' ==
=== Communications ===
Electronic communication should be facilitated in all zones of the ACS by the provision of device charging stations, and wifi.
=== Visitors entry point ===
Visitors are strongly discouraged from entering the ACS.
*In paediatric wards, one parent may be accommodated to visit a patient. In such cases, direct access for the visitor should be provided so that the visitor does not need to pass through the general patient area. Appropriate PPE must be donned before entering the patient area and hand washing/sanitising must be done when exiting the area.
*Non-patients who are accompanying suspected patients to the facility for testing or admission must be accommodated in a well-ventilated, spacious waiting area. Signage in such waiting areas must inform visitors about symptoms, hand hygiene and PPE.
*Hand washing/sanitizing facilities should be provided.

=== Staff areas ===
==== Staff change rooms ====
A minimum of 9m² or 4m² for a single person, increasing by one m² for each additional person is required. The clean (street side) and dirty (contaminated facility side) of the change room should be separated by a step-over barrier.

==== Staff rest areas ====
Staff rest areas within the main facility should be provided with access to kitchenette facilities and staff ablutions.
=== Staff auxiliary services ===
'''Staff on-call:'''Since staff may be required to work long hours or could be required to be on-call, shared, overnight sleeping facilities can be provided for staff on duty, outside the contaminated area, but in close proximity on the patient areas. An example is set out in the diagram below.
[[File:Example of on-call sleeping area for staff.png|center|600px|thumb|Example of overnight sleeping area for staff]]

'''Staff accommodation:''' It is advisable to provide some staff accommodation for off-duty staff who may not have suitable alternatives, for example homes too far away, transport limitations or the requirement not to expose family members to risk. This should be provided in the vicinity of the ACS, but in a physically separated zone. This amenity can be outsourced.

== '''Support Services''' ==
=== Workflow principle ===
[[File:Linen processing cycle.png|none|thumb|Linen processing cycle <ref>IUSS 2014 [https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department]</ref>]]
Progressive workflow from “dirty” (that is contaminated) to “clean” linen is advisable to reduce the risk of exposure to contaminated materials. The workflow diagram below, showing the progression from the dirty linen receiving area, to the cleaning process, to decontamination and drying, and finally sorting and packing, and storage, illustrates this principle.
=== Laboratory ===
[[File:Example of modular laboratory.png|right|thumb|Example of modular laboratory]]
The WHO recommends the following laboratory diagnostic equipment be accommodated:<ref>WHO 2020, [https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items]</ref>.
<nowiki>• Lab screening test kit
• Lab confirmation test kit
• RT-PCR kit
• Extraction kit
• Cartridges for RT-PCR automatic systems
• Swab and Viral transport medium
</nowiki>
Additional accommodation requirements are:
# Reception counter- receiving specimens
# Testing with perspex/ glass screen
# Receiving/Data capture
# Specimen holding
# Toilet - staff
# Blood storage fridge
Can be provided as a modular laboratory unit as shown in the diagram.
=== Pharmacy ===
The purpose of the pharmacy is to provide medicines needed for inpatient treatment and care.
All medical supplies should be stored in a secure, climate-controlled area in close proximity to the patient treatment area. The pharmacy must have dry, lockable, climate-controlled storage of medications. Most pharmaceuticals are labelled with storage temperatures. The pharmacy should have adequate ventilation through an openable window to prevent humidity from building up in the room. Air-conditioning or mechanical ventilation can be provided, if necessary.

Dispensing areas must be well lit. Worktop in space for stock records and administration. Dispensing counters to have perspex or glass screens to serveries. Social distancing implemented at counter, between pharmacists/assistants and between chairs in waiting area.

Can be provided in a mobile unit.

=== Radiology ===
The purpose of radiology services is to provide chest X-Ray services for COVID-19 diagnostics. In general, CT scans, bucky rooms etc. associated with some radiology equipment require specialised infrastructure and therefore is not suitable for ACS. Radiology services can be provided as a mobile floor standing unit, or containerised unit. Alternative technologies such as Lodox and hand-held ultrasound devices are being investigated as potential options and could be confirmed as suitable for use in due course.
=== Laundry services ===
All dirty linen should be handled for bagging or binning inside the patient room/cohort area. The clean linen stock should be stored conveniently close to clinical areas, in a dedicated clean area in the uncontaminated zone. Used linen should be stored in a designated, safe, lockable holding area while awaiting collection. Interim storage areas for soiled linen at the wards is allowable; this may be in dirty linen/ utility room.
Any clean linen for PUI areas should be handled in spaces physically separate from dirty linen of confirmed patient areas. It may be necessary to completely separate PUI and confirmed patient linen streams. Soiled linen and clean linen bags and bins should be dedicated and not mixed.
Full laundry cleaning and drying services may be provided on-site or outsourced. If laundry cleaning and drying services were already rendered on or for the host site before it is repurposed as an ACS, then a suitability and risk assessment should be conducted to ensure that the volumes of laundry generated and infection prevention and control measures are conducive and modifications made as necessary. A new full laundry service may take time and resources to establish, and in general, will not be established at a host site as a temporary solution. Where the site and circumstances advocate for the design of a new laundry or the upgrade of an existing laundry, the IUSS Laundry Services for Hospitals should be applied.
==== Siting and model selection considerations ====
When an existing laundry is being assessed for use or a new one is being planned the following considerations apply:
* Water and power capacity.
* Ease of access to the ACS’s main corridors and internal transport routes.
* The noise factor of the facility and its impact on nearby patient care departments.
For outsourced departments:
* Delivery areas to allow sufficient space to ensure that vehicles can manoeuvre and park easily at the reception and dispatch bays.
* Access to the ACS service roads and public roads.
==== Functional requirements ====
The most basic equipment needed in a laundry includes washing machines, tumble dryers and ironing machines. Equipment requiring steam is not recommended for a temporary facility. The sizing of the laundry, equipment and engineering services can be modified based on the principles provided in the IUSS Laundry and linen.
=== Catering services ===
Kitchenettes, that is, areas for tea, coffee and snacks, mainly for staff, in staff pause areas are discussed elsewhere in this document.
Catering services (for staff and patients) may be provided on- or off-site. If the ACS is to be established with easy access to a suitable, existing, functional kitchen service (e.g. hotel, military or hospital catering) which can meet the additional demand of the ACS, then this should be used. If there is no suitable facility, catering should be outsourced via a suitable off-site supplier. Only in the event that no feasible or suitable, existing facility or local supplier is available, should a new catering service be established at the ACS. Detailed guidance for the sizing, design and layout of catering services can be found in the IUSS Catering Services for Hospitals.
The kitchen (for on-site catering) or preparation area (for off-site catering) should be located with easy access to the point of delivery and storage of food. Adequate food and equipment storage space must be provided.
It is recommended that patient and staff meals, where provided, be supplied in disposable, containers, suitable for incineration, and that these are disposed of as risk waste immediately after use.
Where off-site catering is used, a suitable area for receiving should be provided. Space will be required for sorting meals for distribution and collecting and storing dirty dishes, washing dirty dishes, if necessary, and disposing of left-over food and disposable containers and utensils. The size of the areas required for this will depend on the number of meals delivered.

=== CSSD ===
The primary function of a Central Sterile Supply Department (CSSD) is to provide an efficient, economic, continuous and quality supply of disinfected and sterilised items, when needed, to all patient-care service points in the ACS, and to receive returned contaminated items for cleaning.
CSSD with limited sterilisation capacity (autoclave) but sufficient disinfection capacity (instrument washing). The layout requires a designated clean and dirty areas with a hard barrier between to avoid cross-over of staff and equipment. Work is unidirectional - flows from dirty – to clean - to sterile areas.
This yields three distinct zones:
1. Receiving and cleaning with pass-through windows
# Dirty receiving with Perspex or glass partitioning
# Dirty utility
# Decontamination and cleaning/wash area with throughput instrument washing
# Trolley wash/Park – external
2. Inspection, assembly and packaging with pass-through windows
# A tabletop autoclave
# Instrument washer
# Clean Packing area
3. Sterile processing, storage and distribution. (Separate issuing area from receiving area) with pass-through windows
# Store -linen and consumables
# Sterile pack store
# Issue - Collection hatch with Perspex or glass partitioning
Must also have a secure, separate receiving area for consumables receiving and storage.
An example of a CSSD unit is shown in Figure 21.T

[[File:An example of a small CSSD facility.png|600px|thumb|none|An example of a small CSSD facility<ref>IUSS 2014, https://www.iussonline.co.za/norms-standards/support-services/24-central-sterile-service-department</ref>]]

To be understood: Quality of services, eg. water (including a source of distilled or ionised water for rinsing of bronchoscopes) and electricity, quality of management, if equipment is appropriate for needs and fit for purpose, what is required of the equipment in the near and far future (relocation?), compliance with S.A. National Standards for CSSD, compatibility of equipment and devices, correct chemicals, maintenance of equipment, training of operators. Although the use of disposable breathing circuits and accessories (masks) should be encouraged, the capacity to disinfect these items if disposable is not available must be considered.

The CSSD must be sized to serve the ACS. Considerations are workload and space requirements. CFSA has extensive [https://www.fidssa.co.za/Content/Images/CFSA_SOP_2018.pdf standard operating procedures] for CSSD.

Workload: Number and type of procedures, number of procedure rooms, eg for bronchoscopy, operating hours, available inventory, volume of work and peak times, degree of mechanization, eg. manual or automated instrument washing, amount of product to be stored – chemicals, barrier wrap, chemical indicators, etc., storage and distribution records, quality records – eg. equipment checks, disposal needs.

Space requirements: Space for separation of clean and dirty, allow for unidirectional movement, allow space to manoeuvre trolleys (queue, pack/unload), reduce lifting and carrying heavy items, reduce awkward movements, allow for tidy work areas. Insufficient space will compromise sterility!

Preference should be given to construction materials and finishes which are suitable for frequent cleaning and tolerant to chemicals, including bleach (sodium hypochlorite). Impermeable flooring, non-slip and smooth washable walls are needed. Joints at walls and floors and coving at wall edge, and exposed drains should be avoided. Worktops should be sealed and should be ergonomically suitable.

Ceiling heights below 2.8m may be vulnerable to damage from humidity Where steam and moisture are generated. Noise – insulation of washer-disinfector and steriliser in technical walls will reduce noise. Lighting: Natural light if possible – windows sealed. High luminance if artificial lighting. Open, slatted shelves for sterile store area. Sinks for manual washing: At least two basins, deep (25cm at least) basins, 91 cm from floor, wide and long enough for the biggest instrument tray or container, water ports for flushing of lumens.

The CSSD space allocation and layout should be determine based on what procedures and which medical devices will be required. A typical [[equipment list is provided here]].

=== Maintenance and cleaning ===
Maintenance and cleaning services must be accommodated with offices located away from clinical areas.

=== Mortuary services ===
The National Department of Health has issued guidance on handling of dead bodies and infectious remains<ref>National Department of Health South Africa, 2020 [https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf]</ref>, which should be applied to ACS. While some guidelines have recommend that bodies of persons who have died from COVID-19 should only be held for a very brief period prior to cremation or treatment for burial<ref>Zhejiang University, 2020 [http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm]</ref>, the WHO holds the view (at the time of writing) that there is no evidence of persons becoming infected from exposure to bodies during normal ceremonial and burial activities. However, appropriate PPE should be used when handling such bodies with additional airborne precautions to be taken during autopsies<ref>WHO, 24 March 2020 [https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf]</ref>.

Either body cabinets or a refrigerated room could be used for body storage.
==== Location and layout of mortuary service ====
It is likely that not all alternative care sites will have a mortuary. Those without a mortuary must have a holding room that is located away from general access areas. This holding room must be suitably sized and conditioned. A recommended room size is 3.5 m x 3.4 m<ref>IUSS Adult Inpatient Services, 2014, [https://www.iussonline.co.za/docman/document/clinical-services/65-adult-inpatent-services-gazetted/file]</ref>
A mortuary should be located so that it is easily accessible to mortuary staff and related service providers and visitors without presenting either aesthetic, emotional or ethical problems for unrelated staff, patients or visitors. It should be separate from the general facility, allowing access for the family to view a body without passing through any potentially contaminated area of the facility. The visitors’ entrance should be external and completely separate from other access points.
Appropriate routes should be designated so that bodies are not moved through public-access areas.
==== Sizing of mortuary ====
The layout and size of a mortuary are largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.
==== Services ====
The following services are required in a mortuary:
* Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.
* Sluicing facilities are to be provided in both the body-preparation and autopsy areas if they are not a common area.
* Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush-fitted stainless steel grids.
* No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.
* The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.
* Anti-backflow devices should be fitted to the water-supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.
* Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.
==== Finishes ====
Wall and floor finishes should be impervious to liquids and easily cleanable.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Environmental Controls''' ==

== '''General Indoor Environment Conditions''' ==

Existing environmental control systems should be modified to suit requirements in the facility. The following issues should be considered:
* Systems should be set to maximise the introduction of fresh air and maintain the pressure regime (see ventilation).
* The following internal temperature range should be maintained 19 - 24oC.
* Cooling systems should be able to cater for projected internal heat gains from people, lighting and equipment. Indicative heat gains in treatment areas are 8W/m2 from people, 15W/m2 from lighting and 3 W/m2 equipment and in critical care areas 16W/m2 from people, 15W/m2 from lighting and 60W/m2 equipment.
*As heat gain can vary widely between items of equipment, heat gain and utilisation rates for equipment should be obtained from the manufacturer to establish this more accurately.

=== Solid waste from ACS ===
According to the National Department of Health COVID-19 Environmental Health Guidelines
“All solid waste from the facility should be regarded as potentially infectious material and therefore appropriate precautions should be taken". The management of healthcare risk waste (HCRW) should follow the correct identification segregation, storage and disposal processes as indicated in SANS 10248-1.

* HCRW is segregated at the point of generation and shall be containerized to minimize the risk of contamination.
* Waste generated from patients in isolation or quarantine in a designated facility health facility is treated as health care risk waste (HCRW) as per SANS 10248-1-2008.
* The HCRW is properly packaged in a sealed, leak and puncture-proof containers/ boxes.
* The HCRW is labelled with the biohazard symbol/ sign and marked “Corona virus or COVID-19”.
* The HCRW is stored separately from other waste generated.
* The collection, transportation, treatment and disposal is provided by only an appointed/ appropriate contractor/ service provider, however, ensure that waste is safely stored until the health care waste management company can pick it up and that the company knows and acknowledges that waste was generated by suspected or confirmed COVID-19.
* The waste management company collecting must ensure that and treated and disposal is conducted at license waste treatment/ disposal facilities .
* All personnel or staff in contact with patients must be geared with appreciate personal protective equipment (PPE’s) at all times to prevent exposure or risk to health.
* Monitoring should be done at such facilities.
* All, bags, bins and boxes must be adequately sealed, as not to leak any fluids, and must be wiped down with 0.05% chlorine solution

Measures developed should consider the following.
* Develop a waste management plan following national guidelines and best practice standards for the disposal of medical waste (WHO, 2020).
* Establish procedures with medical waste service providers to regularly pick up the waste and dispose of this safely.
* Provision should be made for 5kg of solid waste per bed per day and this should be monitored and supplemented where it appears this may be inadequate.
* Ensure that access to waste is secure and controlled, for instance, by using lockable waste 1000l containers kept in a location that can only be accessed by health facility and nominated service delivery staff.
* Vermin control programs must be implemented throughout the site with HCRW collection points prioritised
* Provision for safe cleaning and disinfection of reusable containers should be provided. Cardboard, single-use HCRW boxes are removed from site and incinerated.
* Waste must not be allowed to accumulate or be stored inappropriate or unsecured containers.

== '''Engineering Services''' ==
Engineering services include patient services, ventilation, electrical power, water, medical gases, oxygen, compressed air, vacuum, lighting, and fire safety that support the needs of the patients and medical staff under normal and emergency situations. Good practice standards are provided in:
* IUSS Building Engineering Services<ref name = "IUSSBES">IUSS 2017, [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file]</ref>
* NHS Nightingale Instruction Manual<ref name="BDP2020">BDP 2020, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf]</ref>.
The guidance below draws on these and other manuals and standards. 

=== Building ventilation ===
==== Mechanical ventilation ====
While SARS-CoV-2 RNA has been detected in aerosol form, in experimental mechanical aerosolization studies, it is primarily spread through droplet and contact spread and the potential for airborne transmission is thought to be low.
However, the following advice is provided by ASHRAE regarding HVAC systems in general spaces (not specific to healthcare):
Effective high levels of ventilation must be achieved in the facility. Existing ventilation systems should be tailored to suit internal layouts and requirements and the following measures should be taken.
* Mechanical systems should be set to maximise fresh air supply to the facility. There should be no recirculated air without HEPA filtration or other validated decontamination processes.
* A pressure regime should be established, as shown in figure 2, to 'push' air from clean areas, to dirty areas and then out of the building.
* A clean air supply of over 10 L/s per person should be targeted for odour control.
* Fresh air supply shall not be located near patient beds to avoid drafts in winter.
* Extraction points can be located near patient beds in isolation wards or at a high level in long-stay wards. Short-circuiting of air between high-level supply and extraction is a performance risk in winter.
* Noise from ventilation systems and fans shall be below 45 dBA
* Protected lobbies, internal partitions, door arrangements, fans and extracts should be used to maintain the pressure regime and airflow as indicated in the diagram below.
 

[[File:Ventilation in temporary facilities.png|600px|thumb|none|Ventilation in temporary facilities<ref name="BDP2020"/>]]

==== Natural ventilation ====
The airflow direction between naturally ventilated zones may fluctuate according to the wind direction. This is not of concern within and between contaminated zones where occupants are either protected with mandatory PPE or confirmed to be infected with disease strains similar enough so as not be able to reinfect others. Where levels of occupant susceptibility to an airborne disease is significantly different, the less susceptible areas (such as PUI areas and uncontaminated areas) shall be protected from the naturally ventilated and contaminated areas by mechanical ventilation systems with a capacity sufficient to overcome the expected natural ventilation pressure fluctuations (typically 5-15Pa). Where such mechanical ventilation systems are not feasible or expected wind pressure is too great, zone adjacently must be avoided.

===Ultraviolet germicidal Irradiation===
The application of Ultraviolet Germicidal Irradiation (UVGI) for room air disinfection is well understood and is proven to be effective in the disinfection of microorganisms including M. tuberculosis (TB) in air. UVGI should, therefore, be considered as a valid element in indoor airborne infection control strategy for high volume settings. Studies have demonstrated the importance of good vertical air mixing in the room, and the safety of UVGI application. In areas where UVGI is indicated, the design and development of UVGI systems should be in accordance with the [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]<ref>van Reenen et al,2019 [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]</ref>

=== Electrical power ===
Sufficient and reliable power must be available at the facility for envisaged medical equipment, medical gases, lighting and building ventilation equipment. Power installations for the temporary facility can be divided into three zones as indicated below. These are existing services, the temporary service zone and services in each bay.
The following should be considered by competent engineering professionals.

=== Existing services ===
*Capacity: Evaluate whether sufficient power to accommodate envisaged medical equipment, additional lighting and heating, building ventilation and air conditioning can be provided. If existing capacity is insufficient, investigate if it is possible to route additional power from additional locations/transformers around the site or from adjacent sites.
* Safety: The existing electrical distribution network must be able to supply the required equipment load. If this is insufficient/appears unreliable, identify how this can be supported.
* Resilience: Evaluate back-up power and a UPS capacity against essential services demand. If existing capacity is not sufficient, source and establish temporary service capacity.

=== Temporary service zones ===
*Identify locations for temporary service zones where equipment can be located.
*Ensure that equipment and maintenance access is safe and easy.
*Ensure that all distribution boards, circuit breakers and cables are clearly labelled.
=== Services in each bay ===
*Provide pre-wired power strips/trunking as per bay requirements.
*Check that these include sufficient electrical outlets and service points for envisaged equipment.
*Ensure that trunking will carry required equipment loadings. The IUSS Building Engineering Services Guide can be used to check requirements<ref name = "IUSSBES"/>.

[[File:Layout_of_power_in_a_temporary_installation.png|600px|thumb|none|Layout of power in a temporary installation <ref name="BDP2020"/>]]
----

=== Water ===
Water points are needed for handwashing, showers and cleaning. The following issues need to be taken into account.
==== Supply ====
Onsite cold water storage, dedicated to the domestic water requirements of the facility, should be provided. A minimum usable volume of 500 litres per bed should be available.
Hot water storage and consumption should be confirmed by an engineer, as follows:
*Storage 25 L per bed.
*Consumption 180 L/bed.day W/O laundry; 250L /bed. day W laundry.

==== Handwashing ====
See infection control for clinical wash-hand basins
==== Showers ====
Showers for staff coming off shift should be available. Staff flow routes exiting contaminated treatment areas should pass through gowning and shower areas.
----

=== Medical gases, oxygen and vacuum (suction) ===
Medical gases, oxygen and vacuum services will be required in the facility. Mobile gas supply requires piping between supply and patient and clutter floor space. Preferably used fixed installations for patient rooms/cubicles, if possible.

System capacity and point of use pressures and consumption rates are to be ensured at all points. WHO provides technical guidance on [https://www.who.int/publications-detail/oxygen-sources-and-distribution-for-covid-19-treatment-centres oxygen sources and distribution]. 
[[File:Medical gas service layout.png|6oopx|thumb|Medical gas service layout<ref name="BDP2020"/>]]
The following points should also be taken into account.
* For centrally supplied medical gas and vacuum services, system resilience and availability must be ensured.
* Compressors, tanks, accumulators, VIEs, headers and controllers must be secured from uncontrolled access.
* Where possible, gas piping should be reticulated below floors or in ceilings to ensure protection from tampering, damage and ease of access.
* Where reticulation is within open areas, high-level reticulation with point-of-use droppers is advised. Low-level reticulation within rooms is to be avoided.
* Flexible piping can be used, ensuring it does not present a contamination or fire risk and should comply with local regulations. Special care should be taken with flexible O2 piping, keeping it to a minimum.
* Vacuum piping may be contaminated, where point-of-use filtration and collection systems fail. Precautions should be taken when demounting or disconnecting temporary vacuum lines.
* Ensure that oxygen pipelines are designed to provide sufficient flow to all oxygen points in the facility. In terms of utilities, oxygen and medical air would be required. A temporary vacuum point can be provided by mobile medical vacuum units distributed throughout the unit.
* Mobile medical air supplies should be considered where reaching piped specifications are not feasible. Where flexible hoses are used for oxygen and medical air special precautions need to be taken. Flexible oxygen piping must be chemically safe for O2 use. Where perishable flexible piping is used for medical air, terminal filtration at the point-of-use may be required at point-of-use. Especially for long-term use.
* Electrical and gas services can be reticulated against pipe racks or boards fixed to the bed-heads for head to head bed arrangements.
* Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.
* Gas service outlets to be labelled and colour-coded with 3mm lettering.
* SANS 7396-1 should be used to specify the requirements from design to commissioning of medical gas and vacuum systems.
* Medical gas and vacuum pipelines shall be marked per SANS 7396-1 and ISO 5359, as applicable.
* Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.
* SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.
* Plain-ended copper tubing for low-pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.
* Laboratory gas taps and valves shall be marked as described in SANS 10140-4.

=== Lighting ===
Existing lighting systems may need to be modified to suit the clinical requirements in the facility. High bay lighting presents inadequate colour rendering quality for the accurate detection or easy diagnosis of certain clinical conditions. This needs to be evaluated in the selection of supplementary lighting systems.
*Lighting levels should be provided in line with the indoor lighting levels recommended in the Table 6 of IUSS Building Engineering Services .
*Mobile task lighting systems may be adopted in the serious and critical stay wards to supplement incorrect lighting quality.
*Emergency lighting and illuminated emergency egress signage should be linked to the back-up power system.
*External security lighting in external parking areas and spaces around the building should be enhanced to ensure the security of medical staff who need to change shifts at night.

=== Fire safety ===
A functional fire alarm system should be available to support the patient care setting. Fire is a very real threat due to the possibility of an oxygen-enriched atmosphere developing so ventilation is crucial.
The use of temporary facilities for medical care should note the following fire risks (NHS, 2020):
*Patients may have a very high dependency.
*Areas are not specifically designed for patients and do not meet guidance on fire compartmentation and progressive horizontal evacuation.
*Large numbers of patients supplied with oxygen up to 10 litres per minute.
*Possibility of oxygen concentrations exceeding those generally found in the atmosphere- less risk if effective ventilation or large volume i.e. high ceilings.
* Possibility of storage, in excess of 40 litres, of alcohol-based chemicals (such as hand-rub), necessitating a flammables cabinet on site.
*Staff who may not normally work together .
*Staff who may not be familiar with the area.
*Staff not trained in fire safety, progressive horizontal evacuation or oxygen isolation for the specific area.
These factors should be taken into account in fire risk assessments which should then address significant findings in an action plan. Fire assessments should be undertaken by a qualified person and shared with operations and building management staff within the facility. Measures developed should include:
*An automatic fire detection system
*An emergency egress plans are prepared that include patients who have a very high dependency.
*Signage, notices and lighting are installed and are working effectively.
*Management processes are in place to minimise the risk of fire from ignition sources, fuels and oxygen.
*Staff are trained and a fire safety guide sheet for staff is developed and issued.
*Emergency egress routes are kept clear.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Additional Resources''' ==
=== [[Directory of Service Providers|A Directory of Service Providers can be viewed here]] ===

=='''References'''==
<references />

[[Category:COVID-19| ]]
[[Category:Alternate Care Sites|Alternate Care Sites]]

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[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19|(Return to Top)]] 
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Infrastructure Guidance for COVID-19/Alternate Care Sites

2020-05-08T08:43:01Z

Peta: /* Staff auxiliary services */

[[Infrastructure Guidance for COVID-19|Return to Infrastructure Guidance for COVID-19]] 

== '''Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19'''==

This guidance work was initiated under the project titled: 
''Reducing Nosocomial and Community-Acquired Tuberculosis by Strengthening the Capacity of the South African Department of Health to Improve Implementation of Infection Control and Waste Management at All Levels of the Health System Under the President's Emergency Plan for AIDS Relief (PEPFAR)'' 

== '''Purpose and Approach''' ==
The global pandemic of COVID-19 caused by the coronavirus, SARS-CoV-2 is likely to result in a surge in need for medical care for Severe Acute Respiratory Syndrome (SARS) in South Africa. Considering the course of the pandemic in other countries, it is anticipated that South African hospitals will not have sufficient capacity to cope with the surge of persons requiring medical attention and that surge capacity via alternate care sites (ACS) will need to be established.
Surge capacity, contemplated here is not the frequent emergency department overcrowding experienced by healthcare facilities (e.g. Friday/Saturday night emergencies) or local casualty emergency that might overcrowd nearby facilities and have little to no impact on the overall healthcare delivery system. It is when a catastrophic event occurs and the affected population seek medical care from existing local healthcare facilities, causing healthcare infrastructure to become exhausted due to excess in demand. During a healthcare surge, the standard of care will shift from focusing on patient-based outcomes to population-based outcomes, and providers should anticipate “a shift to providing care and allocating scarce equipment, supplies and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals.”<ref>[https://asprtracie.hhs.gov/technical-resources/resource/491/altered-standards-of-care-in-mass-casualty-events Health Systems Research Inc., 2005]</ref> 

Surge capacity can be temporarily established in non-traditional environments, such as hotels, exhibition halls, community halls, and as field hospitals, on open spaces. 

In the context of this document, a quarantine site is a facility for patients who do not require continuous professional medical care, while an ACS is defined as a temporary facility that can provide continuous medical care for SARS. This document provides principles and considerations, high-level guidance for minimum requirements and examples for ACS. 

While an extensive set of health facility guidelines does exist<ref>[https://www.iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-servi IUSS Building Engineering Services (2017)]</ref>, these are applicable for conventional facilities and thus include services and guidelines that are not necessarily relevant to the treatment of a novel, highly infectious pathogen, with pandemic effects. Moreover, these do not provide well for the rapid and temporary establishment of facilities. 

In order to formulate high-level guidance, [[as invited by Business for South Africa]], the team reached out to professional industry bodies for inputs, in particular the South African Institute for Architects (SAIA), The Gauteng Institute for Architects (GiFA) [https://www.gifa.org.za/ Gauteng Institute for Architecture] and the [http://www.safhe.co.za/ South African Federation of Hospital Engineering (SAFHE)], by inviting input via a 36-hour research charrette. Relevant historical and contemporary literature was consulted, precedents identified and critically reviewed. An interaction with the team at Wuhan responsible for makeshift hospitals and emergency infectious diseases hospitals, Central-South Architectural Design Institute, was arranged with assistance of the Chinese Embassy. Material from the [[Infrastructure Unit System Support|Infrastructure Unit System Support (IUSS)]], international literature and guidance and input gathered from the broader architectural, engineering and healthcare professional communities was synthesised and moderated by the CSIR team. The draft was reviewed by an expert review panel. 
=== Acknowledgement of contribution ===
The contributions to the initial version of this were gratefully received. [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Acknowledgements|A list of these contributors can be viewed here.]]. 
New contributions are eagerly encouraged along with debate and discussion on the [[Talk:Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites|'''discussion forum.''']] tab above.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Scope and Assumptions''' ==
ACSs as discussed in this document are dedicated, temporary facilities for triage, testing, diagnosis, further referral and treatment of persons:
*suspected of having contracted SARS-CoV-2, (persons under investigation (PUIs)), who are symptomatic and/or are awaiting results,
*or are confirmed to be infected.
ACS will accommodate a variety of clinical, logistical, support and auxiliary services associated with the render of care. ACS will currently not be licensed to provide healthcare services. Since the ACS will operate in a non-healthcare facility, it cannot fully replace a hospital setting and its prime objective is to manage the patient load until the local healthcare system can meet demands. 

=== Exclusions ===
Quarantine facilities are accommodation facilities where a member of the community can remain for the duration of their isolation period. This is typically temporary housing for a cohort of people who do not need intensive medical attention but who cannot stay at home. Patients can take care of themselves and need limited monitoring by medical staff. Quarantine: Containing presumptive-case patients from each other and the general population.
Quarantine facilities – that is for asymptomatic persons who are in the community in self- or imposed isolation, but not displaying symptoms, or who are symptomatic, but are able to safely recover without clinical intervention and do not need continuous medical observation are not considered in this document.

=== Service regime ===
The following assumptions are made with respect to services under consideration.
* Temporary - limited to the part of the pandemic when the “conventional” hospital platform cannot meet demand. To be dismantled, thereafter.
* Uncomplicated, dedicated COVID-19 care is to be prioritised for ACS.
* Patients with comorbidities, paediatrics will be prioritised for conventional facilities, and only accommodated in ACS as a matter of last resort.
* 24 hour, 7 days a week operations. 

=== Assumed mechanism of transmission ===
Transmission of SARS-CoV-2 is understood to be from person to person firstly by [https://en.wikipedia.org/wiki/Transmission_(medicine)#Droplet_infection droplet] transmission, then by the [https://en.wikipedia.org/wiki/Transmission_(medicine)#Direct_contact contact] route and finally via airborne [https://en.wikipedia.org/wiki/Transmission_(medicine)#Airborne_airborne transmission] during or following mechanical aerosolisation. Water transmission risks are minor, occurring in special [https://en.wikipedia.org/wiki/Transmission_(medicine)#Fecal%E2%80%93oral Fecal-oral] circumstances. Reclassification of transmission mechanisms may nullify some of the approaches presented in this guidance. 

=== A call for strategic coordination ===
This document focusses on infrastructure requirements. These provisions are meaningless without staffing, equipping and resourcing. Whilst staffing, equipping and resourcing are not the focus of this document, these are likely to emerge as key constraining features. Resource constraints are likely to become acute during this pandemic. Doctors and nurses are already in critical short supply in South Africa and internationally, and are themselves susceptible to COVID-19 infection. Equipment and consumables are in short supply with heightened global demand, reduced manufacturing capacity and limits in trade flows. This necessitates strategic coordination, proactive planning, options appraisal and prioritisation. 

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Status Quo''' ==
=== Rationale and transmission status ===
According to the [https://en.wikipedia.org/wiki/World_Health_Organization World Health Organisation] (WHO), based on the largest cohort of COVID-19 patients, about 40% of patients with COVID-19 may have mild disease, where treatment is mostly symptomatic and does not require inpatient care. About 40% of patients have moderate disease that may require inpatient care; 15% of patients will have severe disease that requires oxygen therapy or other inpatient interventions, and about 5% have critical disease that requires the patient to receive mechanical ventilation. However, the evolution of the outbreak in some countries has shown a higher proportion of severe and critical cases and the need to rapidly increase surge capacity to prevent rapid exhaustion of biomedical supplies and staff. In some countries, doubling rates of cases every three days has been observed<ref>WHO-2019-nCoV-HCF_operations-2020, [https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf]</ref> 

South Africa has a high burden of disease, with a high prevalence of [https://en.wikipedia.org/wiki/HIV/AIDS_in_South_Africa HIV and TB]. Although evidence is yet to emerge of the effect of SARS-CoV-2 on a population with these pre-existing conditions, there is reason to proceed with caution<ref>The Conversation 2020, https://theconversation.com/tb-hiv-and-COVID-19-urgent-questions-as-three-epidemics-collide-134554</ref>. There is a potential direct and indirect benefit of ACS to people living with HIV and TB, as well as to general public health and the health system preservation. 

With the travel lockdown in place, and continued transmission, it appears that South Africa is on the cusp between cluster transmission and community transmission according to WHO’s classification, shown in the [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites#Key_clinical_and_infection_control_activities_for_different_transmission_scenarios_.5B3.5D|table below]], indicating that preparation should include temporary hospital facilities and mass critical care.

==== Key clinical and infection control activities for different transmission scenarios <ref>WHO 2020, [https://apps.who.int/iris/handle/10665/331492 https://apps.who.int/iris/handle/10665/331492]</ref> ====
{| class="wikitable"
|-
! !! '''No Case''' !! '''Sporadic Case''' !! '''Clusters of Cases''' !! '''Community Transmission'''
|-
| Faculty Space, Including for Transmission|| Usual Space. Enhanced Screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards). || More patient care areas re-purposed for COVID-19 within the health system, especially for severe cases || Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Staff|| Usual space. Enhanced screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards)||More patient care areas repurposed for COVID-19 within the health system, especially for severe cases||Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Supplies||
*On-hand supplies. Equip wards for COVID-19 treatment.
*Identify essential equipment and supplies, including oxygen.
*Prepare expanded local supply chain
||
*Expanded inventory of supplies with detailed protocols for use.
*Activate expanded local supply chain.
*Prepare national supply chain.
||
*Conservation, adaptation, selected re-use when safe.
*Activate contingency planning and procurement for essential equipment and supplies.
*National supply chain.
*Prepare expanded supply chain at the global level
||
*Activate contingency planning should critical equipment be in short supply.
*Determine allocation of lifesaving resources for HCWs and patients.
*Activate expanded global supply chain
|-
| Standard of Care|| Usual care with enhanced awareness and recognition of immediate needs for first COVID-19 patients|| Usual care and treatment for all patients, including those with COVID-19||Identify context-relevant core services. Shift service delivery platforms. Consider reduction in elective patient encounters, including elective surgical procedures.|| Mass critical care (e.g. open ICU for cohorted patients).
|-
| Care areas expansion|| No requirements for expansion|| Designate 10 beds per suspected COVID-19 case|| Expand COVID-19 patient care areas by a factor of 35 ||Expand COVID-19 patient care areas by a factor of 58
|}

=== Quantification of need ===
At this time there are various parallel initiatives aimed at forecasting the South African epidemic, quantifying the projected need for facilities, and a shortfall in existing capacity. At this time, there is no consensus on this. This section will be updated as further data becomes available.
ACS will prioritise mild to moderately affected COVID-19 patients where basic, targeted medical care will be provided. Should patients’ needs evolve, requiring escalation of care, then the transfer of patients from ACS sites to conventional sites of care will be needed as a matter of course, bringing with it logistical challenges and risks. In the event that the conventional hospital platform is unable to cope, ACS will have pressure to provide care for severe and critical patients, and finally for patients with comorbidity and special requirements, such as paediatrics, persons living with HIV (PLHIV), TB patients and pregnant women. The following pragmatic approach, aligned with the WHO recommended strategic approach, is suggested.
*ACS should preferably be identified with space for expansion.
*The set-up should be done so that levels of care can be upgraded to higher levels of uncomplicated care.
*A secondary upgrade for more diverse package of care may become necessary.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Strategic Approach''' ==
According to WHO, clinical interventions must be put into place immediately and then scaled up according to the epidemiologic profile.
[[File:COVID-19 Resource allocation.png|none|thumb|600px|right|WHO Strategic approach to clinical care]] 
Under this declared state of disaster, the clinical care strategy which cannot be accommodated within existing facilities, can, on a temporary basis be hosted in ACS:
*Within and around existing healthcare facilities, via reconfiguration and/or augmentation.
*In existing non-healthcare buildings suitable for repurposing, such as universities, hotels and conference centres, warehouses, gyms, hostels etc.
*On open fields, including paved parking areas with rapidly constructed, dismountable structures, such as modular tented structures or using rapid modular construction techniques. 

ACS will provide isolation, general (non-acute) care for patients with mild to moderate symptoms and as required, acute care for patients with severe symptoms. Containing confirmed-case patients from general population. Confirmed-case patients can be housed together en masse, while presumptive-case patients must be individually quarantined.
As shown in the WHO Strategic approach to clinical care, the WHO recommends a range of services to meet patient need (''Citation needed''). General (non-acute) care ACS model is designed for minimal acuity patients requiring minimal activities of daily living support (e.g. COVID-positive with minimal symptoms or require <2L of oxygen). Acute care ACS model is designed for higher acuity patients requiring closer monitoring or respiratory support (e.g. COVID-positive with pneumonia or respiratory distress requiring ventilator support). Paediatric patients are to be accommodated in separate wards, where strictly controlled visitation may be allowed. 
As a preliminary estimate, the following ratios of service is proposed:
[[File:COVID Ratios of Service.png|none|thumb|600px|center|COVID Ratios of Service]]

{| class="wikitable"
|-
! '''Case severity, risk factors<ref group="Notes"> Test suspect COVID-19 cases according to diagnostic strategy</ref><ref group="Note"> Known risk factors for severe COVID-19: age over 60 years, hypertension, diabetes, cardiovascular disease, chronic respiratory disease, immunocompromising conditions.</ref>''' !! '''Recommendations'''
|-
|Mild || Patient should be instructed to self-isolate and contact COVID-19 information line for advice on testing
and referral.
|-
|Moderate, with no risk factors ||Test suspected COVID-19 cases according to diagnostic strategy. Isolation/ cohorting in:
* Health facilities, if resources allow;
* Community facilities (e.g. stadiums, gymnasiums, hotels) with access to rapid health advice
(i.e. adjacent COVID-19 designated health post/EMT-type 1, telemedicine)
*Self-isolation at home according to National guidance
|-
| Moderate, with risk factors || Patient should be instructed to self-isolate and call COVID-19 hotline for emergency referral as soon as possible
|-
|Severe || Hospitalization for isolation (or cohorting) and inpatient treatment.
|-
|Critical|| Hospitalization for isolation (or cohorting) and inpatient treatment.
|}

=== Notes and References: ===

<references group = "Note" />
<references />

=== Typology dictates & case studies ===

[[File:NHS Nightingale Hospital London.png|thumb|NHS Nightingale Hospital London <ref name="NHS Nightingale Hospital London">Coronavirus: Building NHS Nightingale Hospital London, 2020 [https://www.bbc.com/news/in-pictures-52092253 https://www.bbc.com/news]</ref>, ]]
To meet the requirements set out in this guidance, prospective “host” sites should be carefully evaluated. The type of “host” site selected will strongly influence or dictate the choice of ACS service model.

No site is likely to meet all requirements and recommendations set out in this document. Adaptations and compromises will be necessary. Services should be provided on site where it is pragmatic to do so, for example where similar services are provided. Outsourcing can also be practical/feasible for some services, such as laboratory services, catering and laundry, provided suitable logistical arrangements can be made.

Some typological responses and service models are set out in precedent examples, shown below. The examples demonstrate that a variety of host settings are workable, provided that the appropriate utility can be contrived.

=== Pragmatic approach ===
Other than in metropolitan areas, co-location of ACS on the premises of, or adjacent to existing healthcare facilities will often be preferable because this is where intensivists and specialist clinical staffing will be available, and support services may be well established. Nevertheless, augmenting capacity at existing facilities should take into account current workloads and capacity to ensure that the COVID-19 surge disrupts normal service provision as little as possible, including continuity of care for patients with chronic conditions and TB and HIV patients. 

*'''[[Infrastructure Guidance for COVID-19/Alternate Care Sites/Case Studies|SARS ACS Precedents and Case Studies can be found here]] '''

=== Notes and References ===
<references />

== '''ACS Infrastructure Planning''' ==

=== Establishing a team ===
A planning team should be formalised to establish the minimum planning and operational requirements for the ACS and to liaise with the local community. The team should include individuals with expertise in the following areas (ideally with knowledge of healthcare delivery under emergency conditions):
*Disaster response / emergency management coordination,
*Clinical care and staffing,
*Infection Prevention and Control practitioners must be involved in all stages of planning, commissioning, in-use, and decommissioning of the facility
*Facility set-up, operations and management,
*Security,
*Transport (patient, staff),
*Engineering and project management,
*Procurement and coordination of supplies, equipment and pharmaceuticals, and
*Community liaison to ensure that concerns of the adjacent population on understood an addressed.
It is important to ensure compliance with health, safety and building regulations, by ensuring the involvement of relevant local authorities. Stakeholder engagement should be formally documented. Concerns and grievances should be systematically addressed.

=== Structural integrity and operational responsibility ===

'''Structural modifications:''' ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered. 

'''Competent person:''' All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed. 

'''Asset responsibility:''' Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented. 

'''Integrity and responsibility'''

'''Structural modifications''': ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered.

'''Competent person''': All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed.

'''Asset responsibility''': Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented.

'''Decommissioning''': Decommissioning of the facility shall be assigned to the competent person discussed above. All residual structures upon decommissioning shall comply with the National Building Regulations. Upon decommissioning, removal of equipment shall be the responsibility of the owner. An infection prevention and control practitioner should be engaged in the decommissioning phase to oversee terminal cleaning and disinfection of equipment and premises.

'''Closure''': Once all patients can be safely discharged or transported back to existing facilities for continued care and there are no ongoing healthcare surge capacity needs, the ACS can be closed. Shut down of an ACS will require decommissioning, identification of new homes or storage for equipment, and termination of ongoing contracts or arrangements. Shut down should be expedited so that the facility can quickly be returned to the control of the existing owners and returned to its usual function.

Action checklist items for ACS closure should include, but not be limited to, the following:
*conduct a site walk-through with the facility owner when shutdown activities are completed to ensure that terminal cleaning and disinfection of supplies and premises, removal of equipment and supplies, and other surge closure activities have been completed to the owner’s satisfaction.
*perform medical records storage procedures.

== '''Site Selection''' ==
When selecting a site, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital can be utilised to determine whether the site is suitable for a 100, 1000 or 2000 bed facility, as required. The following indicative minimum site sizes are needed:
*100 Bed ACS/ hospital conversion, requires ± 4 300 m2
*1000 Bed ACS/ hospital conversion, requires ± 17 600 m2
Evaluation should be done by examining plans (if available), satellite images, drone images, scans and by physical inspection (walkabout). A comprehensive photographic survey should be undertaken and retained for record purposes on the site inspection. This will serve as an audit record and may assist in returning the site to its original function on ACS decommissioning and closure. When scrutinising documents and conducting site inspections to confirm the suitability of a site to host an ACS, the following criteria should be taken into account.
=== Criteria ===
*Affordability (costs, including operational costs known and budget identified),
*Sufficient physical space and capacity to house the immediate need, with the potential to accommodate physical space requirements. For example, open site should not be sloping,
*Legal rights and encumbrances, including renewal opportunity,
*Good access to highway and main roads,
*Well secured perimeter and limited controlled access points,
*Proximity to other hospitals and care sites,
*Accessibility for key staff and public transport,
*Good vehicular access around the site to set up temporary equipment such as back-up generators,
*Free from clear and present danger,
*Outside attenuation zones, floodplains,
*Outside high wind zones,
*Structure in good repair,
*Effective onsite facilities management team who understand how systems work,
*Potential for expansion, if required,
*Access to sufficient capacity for
**potable water,
**adequate sewage,
**telephone,
**internet access with sufficient bandwidth,
**electricity,
*A zone for cleaning, disinfection, and decontamination of equipment at least 15 metres away from occupied areas with access to water, a hard impervious surface and drying areas in the sun, with runoff discharge into the sewer and not into marine ecosystems or the environment. Include area for cleaning and storage of cleaning equipment.
*Likelihood of acceptance of hosting an ACS by the adjacent and local community

=== Desirable ===
*Durable, cleanable surfaces,
*Large open spaces that can be converted to accommodate temporary structures,
*Good ventilation,
*On-site kitchen and laundry,
*Housekeeping staff (chemical and equipment storage, lockers, rest facility, administration office),
*Space conducive for staff respite area and locker rooms,
*Amenities with universal access,
*Fire protection safety and equipment,
*Elevator access for patients if the building has more than one floor,
*Capacity for expansion, and
*Accessible to at least two roadways to provide continued access in the event that one roadway becomes blocked on inaccessible.

== '''Infection Prevention and Control''' ==
General guidance for COVID-19 [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|Infection Prevention and Control]] can be accessed [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|here]] 

Infection prevention and control in the context of COVID-19 should respond to transmission routes of primary concern for the pathogen of interest (droplet and contact transmission, and management of risk waste) as well as infection risk of a general nature (water and sewerage, airborne transmission – under high TB/HIV burden, and general waste).
In addition to satisfying [https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html standard precautions for all patient care], transmission-based precautions should focus on three pillars: exposure reduction by spatial configuration, operational strategies, and personal protection.
=== Transmission-based precautions ===
'''Droplet and contact spread''': Transmission of SARS-CoV-2 virus occurs via droplet and contact spread. The virus has been shown to persist on surfaces for extended periods of time and is known to be efficient at infecting people. 

'''Medical waste and linen:''' As SARS-CoV-02 is carried in body fluids and faecal matter, disposal of contaminated items (tissues) and cleaning regimes (spaces, garments, linen) should be accommodated carefully in the workflow design and infrastructure provision. A site-specific waste management plan should be formulated in accordance with a site-specific waste management plan with reference to SANS 10248. 

'''Airborne transmission:''' Under exceptional circumstances, the risk of airborne transmission arises for SARS-CoV-2, as detailed below.
{| class="wikitable"
|-
!Airborne Transmission Risk Factors
|-
|
As SARS-CoV-2 is not considered airborne, respiratory protection against airborne transmission is not considered necessary, except where aerosolisation of particles may be a risk.
According to the CDC
*tracheal intubation,
*non-invasive ventilation,
*tracheotomy,
*cardiopulmonary resuscitation, or
*manual ventilation before intubation and bronchoscopy.
According to doctors in the field also when performing
*COVID-19 diagnostic sampling as patients can be induced to cough and sneeze.
*Suspected or confirmed comorbidity of TB is not an additional risk where correct COVID-19 PPE is applied.

|}
South Africa has a high prevalence of TB and HIV, and therefore, although the risk of COVID-19 transmission via the airborne route is not paramount, there is a high likelihood that undiagnosed TB infectious patients may present at the ACS for treatment. TB triage may be challenging in the ACS as there are symptoms in common (coughing) with COVID-19. This country-specific risk is taken into account in this guidance

=== Additional precautions ===
'''Water and sewerage contamination:''' The International Water Association [[Infrastructure Guidance for COVID-19/Alternate Care Sites/COVID-19 A Water Professionals Perspective|concluded]] that water and sewerage contamination is not considered to be a key risk factor for COVID-19. The panel expressed concern for “how waste and specifically wastewater (medical) would be handled by places (e.g., hostels, hotels) that are used to serve as interim COVID-19 quarantine or testing facilities or accommodation ([ACS]. These are places other than hospitals that are used in the interim for such purposes and do not usually handle wastewater from medical settings. Such facilities should be monitored carefully.” 

== '''Spatial strategies for infection prevention and control''' ==

=== Restricted access and zone control ===
The site will be arranged to establish clear zoning, with a clear restricted zone protocol and access protection. Zones should be deemed to be "contaminated" or "uncontaminated" with clear transition areas between them.

; Contaminated zones
: (also known as "dirty areas") are areas occupied by COVID-19 infected persons, PUIs, equipment, materials and supplies which have come into contact with such persons without yet undergoing a decontamination procedure. These areas will include patient ward areas and ablutions, patient admissions (including ambulance drop-off) and the associated clinical areas. Staff rest and dining facilities should be outside the contaminated zone. Limited stock for immediate use should be kept in the contaminated zone. Layout designs should consolidate contaminated zones as far as reasonable, and avoid uncontaminated zones as islands in contaminated zones.

; Uncontaminated zones
: (also known as "clean areas") are areas not generally occupied by PUIs or confirmed COVID-19 infected persons. Equipment, materials and supplies in these areas have not yet come into contact with contaminated zones or have undergone a decontamination procedure. These will include clinical management planning rooms, stock rooms, bulk stores, pharmacy, laboratory areas, kitchen and laundry.

; Transition zones
: (also known as intermediate zone) are the spaces through which transfer of people and goods from uncontaminated to decontaminated zones, and vice versa, occur. Materials from the contaminated zone should be decontaminated or contained in the transition zone. The transfer of goods and persons should be highly ritualised and, as far as possible, traffic across transition zones should be minimised. Transition areas should be strategically located to serve this function. Separation of in-going and out-going transfer of goods and persons is preferable. Transition areas include ambulance, trolley decontamination, CSSD, laundry and waste bagging areas, patient locker area and staff change areas with spaces for donning and doffing of PPE.

=== Site layout and master-planning ===
Spatial configuration and layout can ensure unnecessary cross-over of function is avoided. This entails the systematic separation of functions and the managed transition between activities to facilitate consistency of care, an orderly, efficient work environment, less waste and reduced risk for improved outcomes. To achieve this, functional relationships should first be considered at the site level before being considered at the building level. 

<gallery mode=packed heights=300px style="text-align:left">
Layout for a SARS facility, clustering functions with minimised cross-over.png|center|thumb|Layout for a SARS facility, clustering functions with minimised cross-over <ref name="Layout1">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Layout_for_a_Patient_cohorting_strategy.png|center|thumb|Layout for a Patient cohorting strategy <ref name="Layout3">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Tygerberg Hospital virus triage unit site layout.png|center|thumb|Tygerberg Hospital virus triage unit site layout <ref name="Western Cape Provincial Government, 2020a">Western Cape Provincial Government, 2020 a</ref>
</gallery>

The WHO's Clustering Layout <ref name="Layout1"/> and Tygerberg Hospital virus triage unit<ref name="Western Cape Provincial Government, 2020a"/> show worked examples of building and site layouts, which are configured with these principles, respectively. '''Cohorting''' is defined as clustering patients with similar or compatible clinical needs together for risk reduction, acuity, efficiency and quality management, as illustrated in WHO's Cohorting Layout <ref name="Layout3"/>

=== Workflow ===
Within individual functional zones, the workflow activities can be arranged to proceed from clean procedures to contaminated procedures. In the example below, the staff arrival, PPE donning, doffing and patient flows are worked to have controlled interaction and minimised cross-over

<gallery mode=packed heights=400px >
ACS HCW Flow.png |ACS Health Care Worker Flow
COVID-19 Workflow in small unit.png |COVID-19 Workflow in Small Testing Unit <ref name="Western Cape Provincial Government, 2020b>Western Cape Provincial Government, 2020 b</ref>
COVID-19 Workflow in large unit.png |COVID-19 Workflow in Large Testing Unit <ref name="Western Cape Provincial Government, 2020b"/>
</gallery>

As far as possible, a single direction flow of clean to dirty is recommended for all processes: support services, supply and waste.
The Small ACS unit workflow diagram<ref name="Western Cape Provincial Government, 2020b"/> illustrates the recommended separation of access and exit, separate waiting seats, for persons who may be COVID-19 infected. Separate spaces are provided for donning and doffing PPE. Staff change areas are provided.

In the Large ACS unit workflow diagram <ref name="Western Cape Provincial Government, 2020b"/>, there is a clear separation between staff areas and patient areas. Waiting seats are set far apart to reduce transmission risk. Staff change rooms are provided near the point of entry to the facility for staff to change from street clothes into medical work clothes. To prevent work clothes worn inside the facility from contaminating street clothes, these are kept in separate lockers. A step-over barrier from dirty to clean sides of the change room is helpful to enforce a mind-set of avoiding cross-contamination. Bins for contaminated garments are to be provided in change rooms. Shower facilities are to be provided for staff.

== '''Operational Strategies''' ==
=== Cleaning, disinfection and decontamination ===
Surface and substrate specification, and detailing of all areas should, as far as possible, allow for frequent:
*Cleaning with detergent and water.
*Disinfection with 75% alcohol solution (metal surfaces).
*[https://en.wikipedia.org/wiki/Sodium_hypochlorite Sodium hypochlorite] (1,000 ppm)/ Household bleach.
*Disinfectants listed on the EPA List N<ref>The United States Environmental Protection Agency, [https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 List N: Disinfectants for Use Against SARS-CoV-2 (Last Visited 2020) ]</ref> (for non-critical environmental cleaning).
*High-intensity ultraviolet surface disinfection (UV-C).
*Decontamination and sterilisation of clinical equipment.

=== Goods and waste management ===
Remove any unnecessary furniture, equipment and paraphernalia from all patient care and clinical areas. Provide a clear, secure space for waste management. Any potentially infectious waste materials generated at the ACS should be considered and treated as medical waste (health care risk waste). The applicable legislation is:
*[https://www.gov.za/sites/default/files/gcis_document/201409/35405gen452.pdf The National and Provincial Health Care Risk Waste Management Regulations].
*[https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf National Department of Health COVID-19 Environmental Health Guidelines.]<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>
Waste disposal bins should be positioned near the exit inside each patient rooms or wards to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another patient in the same room.

=== Materials and finishes ===
Floor materials must be:
*Level,
*Free of dust and oil,
*Impervious and smooth,
*Slip-resistant in wet areas (e.g. patient ablutions).
Smooth, cement screed floors are acceptable. Where hosting facilities have carpeted areas, a risk assessment of factors such as durability, hygiene and decontamination needs to be conducted. In cases where the acceptance of carpeted flooring is contradicted (but other factors make it a compelling option), temporary floor finishes or covering can be investigated.

== '''Personal protection''' ==
=== Hand sanitation ===
Where wash-hand basins are not provided, clinical wash-hand basins should be installed, at the minimum rate of provision of one wash-hand basin per 5 beds. Clinical wash-hand basins (see figure below) have a variety of features not present in standard wash-hand basins, which are preferable for infection prevention and control. Where standard wash-hand basins are provided, an upgrade is not necessary. In all cases, there should be no surfaces and no clutter, equipment or supplies in the vicinity of wash-hand basins, including surgical gloves.
<gallery mode=packed heights=400px>
Clinical hand wash basin.png|Handwash Basin <ref>de Jager 2020</ref>
Portable Wash-hand Basin.png|Portable wash hand basins can be provided in ACS <ref name="BDPa">BDP 2020, NHS nightingale instruction manual, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf</ref>
</gallery>

Where wash-hand basins are not available, portable units can be used, as shown above<ref name="BDPa"/>. Mounted brackets for hand sanitisers are to be provided for every two beds, preferably mounted near the foot rather than the head of the bed and at all common touch points such as entry points at ablution facilities, linen room, sluice, storerooms, medicine rooms/cupboards, near refrigerators, telephones, light switches, at entry/exit doors, etc.

=== Personal protective equipment ===
Donning and doffing points for personal protective equipment, and convenient, safe disposal of consumables to be placed at critical key points when entering patient areas.
----

== '''General transmission mitigation''' ==
=== Water and sanitation ===
To comply with National Building Regulations; Hazardous Biological Agents Regulations and National Department of Health COVID-19 Environmental Health Guidelines<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>.

=== Droplet aerosolisation ===
When designating areas for procedures during which aerosolization and airborne transmission risk is high, the building ventilation must be carefully considered to take into account downstream risks. In particular, consider to where potentially contaminated air, arising from aerosol-generating procedures, is exhausted. In general, air exhausted directly to the outside is diluted and considered safe, unless there are openings to occupied spaces near the exhaust air outlet. 

In the event that potentially occupied spaces will receive partially diluted or undiluted contaminated air, or where this is indeterminate, the aerosolising activity should be designated to an alternate area. In the event that an alternative is not available, some treatment regime (air filtration or air disinfection) is necessary. 

In most naturally ventilated settings, the airflow direction between zones may fluctuate according to the wind direction. Such high-risk spaces should not be adjacent to spaces with high susceptibility rates, such as PUI areas and uncontaminated areas. Contaminated areas should not be directly adjacent to clean areas unless mechanically ventilated. 
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|Guidance on COVID-19 building ventilation design is provided here]].

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Health, Safety and Well-being''' ==
In addition to the infection prevention and control measures discussed above, the following should be provided for health, safety and well-being.
=== General provisions ===
*Minimised and controlled entry and exit points, with suitable control.
*Clearly identified accessible and marked routes for patients, staff, goods and waste.
*Clear designation of restricted zones.
=== Site level provisions ===
*Safe staff parking and arrival of staff via planned and public transport.
*Clearly demarcated parking for people with disabilities.
*Arrival and departure point for patients via public transport, passenger vehicles, and emergency service.
*Limited safe patient parking.
*Supply of goods and removal of waste.

=== Within and between buildings ===
*Entrances with a clear opening width (CoW) of at least 900mm.
*Routes with a minimum width of 2 000mm free of hazards, for example, rubbish bins.
*All clinical, patient and support areas to be accessible by trolley.
'''Ramps''' should be of stable construction, capable of sustaining a mass of 300kg. They should incorporate side lips and the surface should be slip-resistant. Gradients should be as gentle as the circumstances allow. (Recommended maximum 1:20). 
'''Small changes in floor levels''' are not desirable, but where these exist are to be clearly marked with reflective paint/ tape, and lit at night
Elevators between different floors, where patients need access (The recommended minimum lift size for patient trolley/stretcher movement is 1 400mm × 2 400mm, however, this may not be possible). 
'''Pathways''' to be lit at night, where used at night. 
'''Staircases''' must be well-lit at night with non-slip surfaces and secure balustrades. 
'''Doors''', Double doors and automated or push-operated doors to all clinical areas are to be preferred, where these are newly installed or able to be retrofitted. Door closers are to be disabled, where not necessary to reduce touch surfaces. Hand sanitisers to be provided at where high touch common surfaces occur (e.g. wall-mounted at doorways).

=== Signage ===
The appropriate level of information to facilitate legibility, orientation and wayfinding. Minimum standards, signage to be:
*Clearly visible, simple font, font size, contrasting colours, placed in the field of vision
*Washable
*Comprehensive safety signage - fire signage (exits, equipment etc.)
*Restricted areas clearly marked
*Identification signage - each patient space to be allocated a unique number and a whiteboard or perspex sheet for writing the patient’s name
Signs should be posted immediately outside of patient rooms indicating appropriate IPC precautions and required personal protective equipment (PPE).
Signage of a temporary nature can be provided on laminated white A4 sheets attached eye-level. The text should be black sans-serif (for instance Arial) text at least 40point size and centrally positioned on the sheet. Detailed guidance on signage is provided in IUSS Inclusive environments.
=== Safety and security ===
Upon identification of the ACS host site, a team should be convened to conduct a multidisciplinary safety and security analysis. These critical team members need to form the working committee responsible for undertaking the detailed assessment of the existing facility’s security. They should analyse data about the security system’s condition and review existing security concerns or issues that are reasonably likely to become concerns in the near future. The figure below represents a five-zone approach to security, which is a recommended, systematic approach to security.
[[File:Zonal approach to security.png|center|600px|thumb|IUSS Security- Zonal Approach to Security <ref name="IUSS Security">IUSS Hospital design principles - Security [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file]</ref>]]
The security strategy should take into account that whilst clinical services and some logistical and support services will be required 24 hours a day, seven days per week, some support services, logistics services and auxiliary services may only be operational for the minimum periods required to meet demand. These functional elements should be capable of being secured, for example over weekends and at night, as the case may be.
Detailed guidance is available in [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file IUSS Hospital design principles - Security] <ref name="IUSS Security"/>

=== Comfort and dignity ===
Supplemental heating: Patient health and comfort are dependent on, amongst others, maintaining body temperature. The ACS structural technology must be selected to achieve the general indoor environment conditions discussed in a subsequent section for all clinical and occupied areas. As we are moving into South African winter supplemental heating may be required, especially in the evenings, in order to avoid hypothermia. Use of fans, bar, radiator or gas heaters should be prohibited. Unless clinical areas can be maintained above 18 degrees centigrade, patients should each have an infrared heater available, in addition to blankets. Personal/ donated blankets can be considered if they are laundered first and could be destroyed upon discharge.
Mobile screens should be available to provide privacy where necessary (e.g. during consultations or procedures).
<gallery mode = packed heights = 400px>
Bed_Isolator_-Vietnam.png|thumb|Flexible Barrier Isolator<ref>WHO. (2020), Severe Acute Respiratory Infections Treatment Centre. Geneva, Switzerland : WHO- World Health Organization</ref>
ACS Cohort beds.png|ACS Cohort beds.png|thumb|Excel Centre London 04-2020 <ref>Architects' Journal 2020, [https://www.architectsjournal.co.uk/news/nhs-nightingale-bdp-on-the-first-nine-days-converting-the-excel-centre/10046749.article https://www.architectsjournal.co.uk/news]</ref>
</gallery>
Some solutions which address patient privacy and dignity are depicted above.

=== Notes ===
<references/>

== '''Schedule of Accommodation''' ==
Based on clinical needs of the ACS, a schedule of accommodation can be crafted capturing the clinical, clinical, logistical, support and auxiliary services associated with the render of care. When deriving a schedule of accommodation, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital tool can be used. Functions to be accommodated are: 
'''Clinical services''': Triage, rapid assessment of persons entering the facility, to expeditiously identify and render the appropriate service. Admissions and registration. Inpatient accommodation is to be organised according to cohorting principles, discussed above. Testing and diagnostics, including laboratories and x-ray. Safe storage and dispensing of drugs to patients.Offices for clinical administration and clinical planning meeting rooms in the clean zone are needed. 
'''Logistical services:''' Logistical services will entail management of flows of people, goods, services and information to and from the site, as well as within the site. It includes security and communication arrangements. Staff entry, preparations to transition from outside to clinical work environment, including pause areas for relief. Emergency services, visitors. Goods, supplies and storage and waste removal and/ or treatment.
Support services key to the provision of clinical services should be separated so that the risks associated with that particular activity can be managed. 
'''Support services are:'''
*Laboratory services
*Catering
*Laundry
*Environmental cleaning and housekeeping
*CSSD
*Maintenance and cleaning of surrounds, eg. waste areas
*Porters/”runners”, stretchers/wheelchairs
*Mortuary
* Security
Support services can be provided off-site, in which case, safe, secure and efficient transfer and logistical arrangements should be designed. 
'''Auxiliary services:''' Auxiliary services are services which may be provided on or near the ACS site, but which are not directly related to core clinical care. This included overnight accommodation for staff who may not wish to return home to avoid exposing their families, or who need rest between shifts, or for discharged patients awaiting transport home, volunteers who have recovered from SARS-CoV-2.
Limited psychosocial services and allied health services may also be provided on or near ACS for example by approved partners.
Examples of schedules of accommodation for patient and support spaces for a protective isolation ward is available [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedule for COVID-19 Isolation Wards|here]] and mild to severe cases [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedules for COVID-19 Wards for Mild to Severe Cases|here]].

== '''Clinical Services''' ==
=== Triage ===
Confirmed COVID-19 cases and PUIs who are referred from a testing facility or a higher level of care, will enter the facility in a triage area to receive vital screening and initial assessment. They will be registered and admitted to inpatient care. They will be assigned a "ward" or section of the facility - based on disease status and acuity. These are Protective Isolation, the Mild & Moderate ward, or the Critical & Severe wards. Patients should be clustered according to gender. As far as practicable, ablutions for each gender, isolation patients, paediatrics and staff shall be separately provided. Paediatrics patients, if admitted, are to be assigned a dedicated section.
As patients recover or deteriorate, they may be relocated to the appropriate section/ ward.
Once the patient has sufficiently recovered and a negative test result is received they will be appropriately decontaminated and discharged, collecting medication from the dispensary on exit. Patient movement between various sections of the ACS will be restricted as far as possible, with mobile radiology units, in-ward medication dispensing and in-ward food service.

=== Inpatient ACS accommodation ===
Separate spaces for:
*suspected, unconfirmed cases, under observation (PUIs), to be accommodated in isolation facilities (separate rooms, if possible);
*patients with confirmed COVID-19 with mild to moderate disease, not requiring dedicated oxygen therapy;
*patients who require dedicated oxygen therapy;
*patients requiring mechanical ventilation; and
*recovered/ confirmed negative.
==== Protective Isolation Facilities ====
Suspected, unconfirmed cases, under observation – persons under investigation (PUIs) to be accommodated in protective isolation facilities (separate positive-pressure rooms, if possible). PUI are restricted to their rooms. All food and laundry services will be brought to the PUI rooms to reduce interaction and potential contamination. All waste will be collected by facility staff and taken to waste handling areas. Infection prevention and control measures are put in place for the handling of used food utensil and laundry as well as waste collection. PUI areas will have restricted access, including for staff serving other inpatient sections, for confirmed cases.

==== Inpatients accommodation for confirmed COVID-19 ====

Inpatient facilities confirmed positive COVID-19 can be accommodated in large shared ‘wards’ with partitioning between patients. Partitioning between patients is optional. Partitioning is preferable to curtains found in conventional hospitals, as they are more conducive to daily cleaning. If curtains are used, antimicrobial treated fabrics with biocide used to treat the curtains has been tested to international standard EN 14476 and shown to be effective against H1N1 Influenza A Virus (Swine Flu), >99.999% kill rate in 5 minutes and measles morbillivirus, >99.99% kill rate in 5 minutes are preferred. If only separate rooms are available, patient monitoring and surveillance will need to be accommodated. This phase of treatment has a lower area/space requirement compared with PUIs, as cross-infection between patients is less of a concern. Shared ablution facilities are acceptable. It is recommended that, at least, two general accommodation ward areas be provided. 

a) Mild and moderate patients, and 
b) Serious and critical patients. 

The room must have openable windows for natural ventilation if a dedicated positive pressure ventilation system is not available. Ducted ventilation systems shall not be shared between PUI areas and confirmed COVID-19 patient areas. 
[[File:COVID-19 ACS - protective isolation – bed layout.png|thumb|center|800px|ACS - protective isolation – bed layout]]
[[File:COVID-19 ACS – mild-moderate patient bed layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient bed layout]]
[[File:COVID-19 ACS – mild-moderate patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient shared ward layout]]
[[File:COVID-19 ACS – severe-critical patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – severe-critical patient shared ward layout]]

Examples above show bed layout with bed spacing for protective isolation, a mild/moderate patient and a mild/moderate patient shared ward and for a severe/critical patient

=== Patient services ===
Patients in ACS will not generally be ambulatory and will be confined to their room, or cubicle in a bed. In general, domestic beds or hospitality industry (hotel) beds are not suitable for patient care. These should only be used where a hospital-grade bed cannot be sourced, as hospital beds are designed for ease of cleaning and decontamination (for infection prevention and control) and with patient and ergonomics, safety and comfort taken into account (they prevent back injury for nursing staff and can help to prevent bedsores). The higher the specification of bed, the more suitable it is for the higher levels of care. Lockers for patients personal belongings should be provided in the uncontaminated zone (in which case bedside lockers will not be necessary), and it is preferable (where bedside lockers are not provided) for overbed tables to be provided, per bed, if possible. 
The following beds are suitable:
*Repaired and refurbished beds from condemned hospital stocks.
*South African National Standard, SANS 521:2013 Edition 3.5, on Hospital beds and cots ISBN 978-0-626-28830-3.
*Beds listed on the National Treasury (See [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Hospital Bed Specification|specification]]).
The table below details the minimum services required at each patient bed. Details on these services are discussed in a subsequent section of the document.

{| class="wikitable"
|-
! Service/ Capacity!!Triage!!Isolation !!Mild – moderate inpatient!!Severe case wards!!Critical case wards
|-
| Power – 16A 230V Single socket outlet||As needed ||1 per bed||1 per bed||3 per bed||6 per bed
|-
| UPS Power – 16A 230V Single socket outlet ||As needed||1 per bed||1 per bed||1 per bed||2 per bed
|-
| Medical Air<ref group="Note">Mobile units recommended for intermittent use. 3 per 20 beds</ref><ref group="Note">There are some ventilators which have built-in compressors allowing them to function without Medical Air. This is however, not the norm. With Ventilators probably being the most difficult medical device to obtain at present, it would be prudent to rather allow for Medical Air at each bed.</ref> (LP)400kPa||No||Yes||No||Yes||Yes
|-
| Medical O2 -400kPa||Portable/shared||Portable/shared||No||One||Two
|-
| Vacuum-40kPa||No||Portable/shared||Portable/shared||Yes||Yes
|-
| Equipment rail||||||||Yes||Yes
|-
| Upper room UVGI||Optional||Optional||||||Optional
|-
| Examination light||No||No||Yes||Yes||Yes
|-
| Room Ventilation rate||60 L/s per person||10 L/s per person||10 L/s per person||10 L/s per person||12 ACH
|}
'''Notes: '''
<references group="Note" />

Two additional 16A 230V single socket outlets, one two-pin outlet and a worktop should be provided for every 32 beds (or part thereof), for:
*Electrocardiograph (ECG): Could be omitted if monitors have a full 12 lead ECG function.
*Blood gas analyser: Could be omitted if a Lab Services are available.
*Staff cellphone charging.

Example of healthcare technology to be provided for critical care patients is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]. Severe patients may be provided continuous positive airway pressure (CPAP). Emergency trolleys (“crash carts”) are to be provided in patient areas with convenient access to patient beds, out of the passage of corridors and is moved to the patient when needed. 1 crash cart for every 16 patients (or part thereof, with at least one dedicated for PUIs. An example of provisions for a crash cart is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]
==== Patient ablutions ====
[[SARS-CoV-2 is found in faecal matter]], so careful management of patient body fluids is crucial and convenient, practical support for frequent cleaning of ablutions especially shared ablutions is necessary. Dedicated ablutions (toilets and showers) are to be provided for patient use. Toilets and showers should be in separate rooms.
Hand washbasins and or/ hand sanitiser should be provided both inside and outside the toilet room so that patients can wash their hands on the way in and on the way out of the room.
*1 toilet for every 8 persons.
*1 shower for every 8 persons.
*1 disabled ablution for every 8 regular ablutions (or part thereof).
*1 disabled shower for every 8 persons (or part thereof).

Critical and severe patients may be sedated and have a reduced need to access ablutions, ablution facilities proximity and provision can take this factor into account. Showers and wash hand basins should have hot and cold running water. Where possible ablution facilities must have openable windows for natural ventilation, if not possible the bathroom extraction and room ventilation system must be reviewed before admitting patient '''(see [[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|ventilation]]).'''

Portable toilets and showers may be used, provided that suitable hand wash facilities are provided. These will need to be suitably located, preferably in decentralised clusters, so that patients can easily access them without needing to walk very far. Ablutions should be located and designed in such a way as to provide visual and acoustic privacy, dignity and avoid disturbance of other nearby patients when accessing, using or cleaning the ablutions. Separate ablutions are to be provided for PUIs and confirmed patients.

====Makeshift sluice areas ====
In conventional hospital settings, sluice rooms are provided for cleaning and sanitation of soiled equipment, such as bedpans. In a temporary setting, such as an ACS, the establishment of a temporary sluice room may not be practicable, and there may not be facilities for emptying buckets, rinsing equipment etc.. The following is suggested:
Allocate a toilet, hand wash basin, not in splash range and restrict access to it for draining buckets and install a macerator for disposal of disposable bedpans. Electrical, water and waste supply points required as per supplier specification.
==== Dedicated patient treatment areas ====
The following dedicated, private spaces per ward for clinical procedures are recommended:
*Counselling and consulting room (can be shared), as shown in the figure below
[[File:Consulting room example layout.png|400px|thumb|center|Consulting room example layout]]
*Minor procedures room, as per the example provided in the figure below 
[[File:Treatment-minor procedures room example layout.png|400px|thumb|center|Treatment / minor procedures room example layout]]

== '''Logistical Services''' ==
=== Communications ===
Electronic communication should be facilitated in all zones of the ACS by the provision of device charging stations, and wifi.
=== Visitors entry point ===
Visitors are strongly discouraged from entering the ACS.
*In paediatric wards, one parent may be accommodated to visit a patient. In such cases, direct access for the visitor should be provided so that the visitor does not need to pass through the general patient area. Appropriate PPE must be donned before entering the patient area and hand washing/sanitising must be done when exiting the area.
*Non-patients who are accompanying suspected patients to the facility for testing or admission must be accommodated in a well-ventilated, spacious waiting area. Signage in such waiting areas must inform visitors about symptoms, hand hygiene and PPE.
*Hand washing/sanitizing facilities should be provided.

=== Staff areas ===
==== Staff change rooms ====
A minimum of 9m² or 4m² for a single person, increasing by one m² for each additional person is required. The clean (street side) and dirty (contaminated facility side) of the change room should be separated by a step-over barrier.

==== Staff rest areas ====
Staff rest areas within the main facility should be provided with access to kitchenette facilities and staff ablutions.
=== Staff auxiliary services ===
'''Staff on-call:'''Since staff may be required to work long hours or could be required to be on-call, shared, overnight sleeping facilities can be provided for staff on duty, outside the contaminated area, but in close proximity on the patient areas. An example is set out in the diagram below.
[[File:Example of on-call sleeping area for staff.png|center|600px|thumb|Example of overnight sleeping area for staff]]

'''Staff accommodation:''' It is advisable to provide some staff accommodation for off-duty staff who may not have suitable alternatives, for example homes too far away, transport limitations or the requirement not to expose family members to risk. This should be provided in the vicinity of the ACS, but in a physically separated zone. This amenity can be outsourced.

== '''Support Services''' ==
=== Workflow principle ===
[[File:Linen processing cycle.png|none|thumb|Linen processing cycle <ref>IUSS 2014 [https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department]</ref>]]
Progressive workflow from “dirty” (that is contaminated) to “clean” linen is advisable to reduce the risk of exposure to contaminated materials. The workflow diagram below, showing the progression from the dirty linen receiving area, to the cleaning process, to decontamination and drying, and finally sorting and packing, and storage, illustrates this principle.
=== Laboratory ===
[[File:Example of modular laboratory.png|right|thumb|Example of modular laboratory]]
The WHO recommends the following laboratory diagnostic equipment be accommodated:<ref>WHO 2020, [https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items]</ref>.
<nowiki>• Lab screening test kit
• Lab confirmation test kit
• RT-PCR kit
• Extraction kit
• Cartridges for RT-PCR automatic systems
• Swab and Viral transport medium
</nowiki>
Additional accommodation requirements are:
# Reception counter- receiving specimens
# Testing with perspex/ glass screen
# Receiving/Data capture
# Specimen holding
# Toilet - staff
# Blood storage fridge
Can be provided as a modular laboratory unit as shown in the diagram.
=== Pharmacy ===
The purpose of the pharmacy is to provide medicines needed for inpatient treatment and care.
All medical supplies should be stored in a secure, climate-controlled area in close proximity to the patient treatment area. The pharmacy must have dry, lockable, climate-controlled storage of medications. Most pharmaceuticals are labelled with storage temperatures. The pharmacy should have adequate ventilation through an openable window to prevent humidity from building up in the room. Air-conditioning or mechanical ventilation can be provided, if necessary.

Dispensing areas must be well lit. Worktop in space for stock records and administration. Dispensing counters to have perspex or glass screens to serveries. Social distancing implemented at counter, between pharmacists/assistants and between chairs in waiting area.

Can be provided in a mobile unit.

=== Radiology ===
The purpose of radiology services is to provide chest X-Ray services for COVID-19 diagnostics. In general, CT scans, bucky rooms etc. associated with some radiology equipment require specialised infrastructure and therefore is not suitable for ACS. Radiology services can be provided as a mobile floor standing unit, or containerised unit. Alternative technologies such as Lodox and hand-held ultrasound devices are being investigated as potential options and could be confirmed as suitable for use in due course.
=== Laundry services ===
All dirty linen should be handled for bagging or binning inside the patient room/cohort area. The clean linen stock should be stored conveniently close to clinical areas, in a dedicated clean area in the uncontaminated zone. Used linen should be stored in a designated, safe, lockable holding area while awaiting collection. Interim storage areas for soiled linen at the wards is allowable; this may be in dirty linen/ utility room.
Any clean linen for PUI areas should be handled in spaces physically separate from dirty linen of confirmed patient areas. It may be necessary to completely separate PUI and confirmed patient linen streams. Soiled linen and clean linen bags and bins should be dedicated and not mixed.
Full laundry cleaning and drying services may be provided on-site or outsourced. If laundry cleaning and drying services were already rendered on or for the host site before it is repurposed as an ACS, then a suitability and risk assessment should be conducted to ensure that the volumes of laundry generated and infection prevention and control measures are conducive and modifications made as necessary. A new full laundry service may take time and resources to establish, and in general, will not be established at a host site as a temporary solution. Where the site and circumstances advocate for the design of a new laundry or the upgrade of an existing laundry, the IUSS Laundry Services for Hospitals should be applied.
==== Siting and model selection considerations ====
When an existing laundry is being assessed for use or a new one is being planned the following considerations apply:
* Water and power capacity.
* Ease of access to the ACS’s main corridors and internal transport routes.
* The noise factor of the facility and its impact on nearby patient care departments.
For outsourced departments:
* Delivery areas to allow sufficient space to ensure that vehicles can manoeuvre and park easily at the reception and dispatch bays.
* Access to the ACS service roads and public roads.
==== Functional requirements ====
The most basic equipment needed in a laundry includes washing machines, tumble dryers and ironing machines. Equipment requiring steam is not recommended for a temporary facility. The sizing of the laundry, equipment and engineering services can be modified based on the principles provided in the IUSS Laundry and linen.
=== Catering services ===
Kitchenettes, that is, areas for tea, coffee and snacks, mainly for staff, in staff pause areas are discussed elsewhere in this document.
Catering services (for staff and patients) may be provided on- or off-site. If the ACS is to be established with easy access to a suitable, existing, functional kitchen service (e.g. hotel, military or hospital catering) which can meet the additional demand of the ACS, then this should be used. If there is no suitable facility, catering should be outsourced via a suitable off-site supplier. Only in the event that no feasible or suitable, existing facility or local supplier is available, should a new catering service be established at the ACS. Detailed guidance for the sizing, design and layout of catering services can be found in the IUSS Catering Services for Hospitals.
The kitchen (for on-site catering) or preparation area (for off-site catering) should be located with easy access to the point of delivery and storage of food. Adequate food and equipment storage space must be provided.
It is recommended that patient and staff meals, where provided, be supplied in disposable, containers, suitable for incineration, and that these are disposed of as risk waste immediately after use.
Where off-site catering is used, a suitable area for receiving should be provided. Space will be required for sorting meals for distribution and collecting and storing dirty dishes, washing dirty dishes, if necessary, and disposing of left-over food and disposable containers and utensils. The size of the areas required for this will depend on the number of meals delivered.

=== CSSD ===
The primary function of a Central Sterile Supply Department (CSSD) is to provide an efficient, economic, continuous and quality supply of disinfected and sterilised items, when needed, to all patient-care service points in the ACS, and to receive returned contaminated items for cleaning.
CSSD with limited sterilisation capacity (autoclave) but sufficient disinfection capacity (instrument washing). The layout requires a designated clean and dirty areas with a hard barrier between to avoid cross-over of staff and equipment. Work is unidirectional - flows from dirty – to clean - to sterile areas.
This yields three distinct zones:
1. Receiving and cleaning with pass-through windows
# Dirty receiving with Perspex or glass partitioning
# Dirty utility
# Decontamination and cleaning/wash area with throughput instrument washing
# Trolley wash/Park – external
2. Inspection, assembly and packaging with pass-through windows
# A tabletop autoclave
# Instrument washer
# Clean Packing area
3. Sterile processing, storage and distribution. (Separate issuing area from receiving area) with pass-through windows
# Store -linen and consumables
# Sterile pack store
# Issue - Collection hatch with Perspex or glass partitioning
Must also have a secure, separate receiving area for consumables receiving and storage.
An example of a CSSD unit is shown in Figure 21.T

[[File:An example of a small CSSD facility.png|600px|thumb|none|An example of a small CSSD facility<ref>IUSS 2014, https://www.iussonline.co.za/norms-standards/support-services/24-central-sterile-service-department</ref>]]

To be understood: Quality of services, eg. water (including a source of distilled or ionised water for rinsing of bronchoscopes) and electricity, quality of management, if equipment is appropriate for needs and fit for purpose, what is required of the equipment in the near and far future (relocation?), compliance with S.A. National Standards for CSSD, compatibility of equipment and devices, correct chemicals, maintenance of equipment, training of operators. Although the use of disposable breathing circuits and accessories (masks) should be encouraged, the capacity to disinfect these items if disposable is not available must be considered.

The CSSD must be sized to serve the ACS. Considerations are workload and space requirements. CFSA has extensive [https://www.fidssa.co.za/Content/Images/CFSA_SOP_2018.pdf standard operating procedures] for CSSD.

Workload: Number and type of procedures, number of procedure rooms, eg for bronchoscopy, operating hours, available inventory, volume of work and peak times, degree of mechanization, eg. manual or automated instrument washing, amount of product to be stored – chemicals, barrier wrap, chemical indicators, etc., storage and distribution records, quality records – eg. equipment checks, disposal needs.

Space requirements: Space for separation of clean and dirty, allow for unidirectional movement, allow space to manoeuvre trolleys (queue, pack/unload), reduce lifting and carrying heavy items, reduce awkward movements, allow for tidy work areas. Insufficient space will compromise sterility!

Preference should be given to construction materials and finishes which are suitable for frequent cleaning and tolerant to chemicals, including bleach (sodium hypochlorite). Impermeable flooring, non-slip and smooth washable walls are needed. Joints at walls and floors and coving at wall edge, and exposed drains should be avoided. Worktops should be sealed and should be ergonomically suitable.

Ceiling heights below 2.8m may be vulnerable to damage from humidity Where steam and moisture are generated. Noise – insulation of washer-disinfector and steriliser in technical walls will reduce noise. Lighting: Natural light if possible – windows sealed. High luminance if artificial lighting. Open, slatted shelves for sterile store area. Sinks for manual washing: At least two basins, deep (25cm at least) basins, 91 cm from floor, wide and long enough for the biggest instrument tray or container, water ports for flushing of lumens.

The CSSD space allocation and layout should be determine based on what procedures and which medical devices will be required. A typical [[equipment list is provided here]].

=== Maintenance and cleaning ===
Maintenance and cleaning services must be accommodated with offices located away from clinical areas.

=== Mortuary services ===
The National Department of Health has issued guidance on handling of dead bodies and infectious remains<ref>National Department of Health South Africa, 2020 [https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf]</ref>, which should be applied to ACS. While some guidelines have recommend that bodies of persons who have died from COVID-19 should only be held for a very brief period prior to cremation or treatment for burial<ref>Zhejiang University, 2020 [http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm]</ref>, the WHO holds the view (at the time of writing) that there is no evidence of persons becoming infected from exposure to bodies during normal ceremonial and burial activities. However, appropriate PPE should be used when handling such bodies with additional airborne precautions to be taken during autopsies<ref>WHO, 24 March 2020 [https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf]</ref>.

Either body cabinets or a refrigerated room could be used for body storage.
==== Location and layout of mortuary service ====
It is likely that not all alternative care sites will have a mortuary. Those without a mortuary must have a holding room that is located away from general access areas. This holding room must be suitably sized and conditioned. A recommended room size is 3.5 m x 3.4 m<ref>IUSS Adult Inpatient Services, 2014, [https://www.iussonline.co.za/docman/document/clinical-services/65-adult-inpatent-services-gazetted/file]</ref>
A mortuary should be located so that it is easily accessible to mortuary staff and related service providers and visitors without presenting either aesthetic, emotional or ethical problems for unrelated staff, patients or visitors. It should be separate from the general facility, allowing access for the family to view a body without passing through any potentially contaminated area of the facility. The visitors’ entrance should be external and completely separate from other access points.
Appropriate routes should be designated so that bodies are not moved through public-access areas.
==== Sizing of mortuary ====
The layout and size of a mortuary are largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.
==== Services ====
The following services are required in a mortuary:
* Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.
* Sluicing facilities are to be provided in both the body-preparation and autopsy areas if they are not a common area.
* Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush-fitted stainless steel grids.
* No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.
* The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.
* Anti-backflow devices should be fitted to the water-supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.
* Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.
==== Finishes ====
Wall and floor finishes should be impervious to liquids and easily cleanable.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Environmental Controls''' ==

== '''General Indoor Environment Conditions''' ==

Existing environmental control systems should be modified to suit requirements in the facility. The following issues should be considered:
* Systems should be set to maximise the introduction of fresh air and maintain the pressure regime (see ventilation).
* The following internal temperature range should be maintained 19 - 24oC.
* Cooling systems should be able to cater for projected internal heat gains from people, lighting and equipment. Indicative heat gains in treatment areas are 8W/m2 from people, 15W/m2 from lighting and 3 W/m2 equipment and in critical care areas 16W/m2 from people, 15W/m2 from lighting and 60W/m2 equipment.
*As heat gain can vary widely between items of equipment, heat gain and utilisation rates for equipment should be obtained from the manufacturer to establish this more accurately.

=== Solid waste from ACS ===
According to the National Department of Health COVID-19 Environmental Health Guidelines
“All solid waste from the facility should be regarded as potentially infectious material and therefore appropriate precautions should be taken". The management of healthcare risk waste (HCRW) should follow the correct identification segregation, storage and disposal processes as indicated in SANS 10248-1.

* HCRW is segregated at the point of generation and shall be containerized to minimize the risk of contamination.
* Waste generated from patients in isolation or quarantine in a designated facility health facility is treated as health care risk waste (HCRW) as per SANS 10248-1-2008.
* The HCRW is properly packaged in a sealed, leak and puncture-proof containers/ boxes.
* The HCRW is labelled with the biohazard symbol/ sign and marked “Corona virus or COVID-19”.
* The HCRW is stored separately from other waste generated.
* The collection, transportation, treatment and disposal is provided by only an appointed/ appropriate contractor/ service provider, however, ensure that waste is safely stored until the health care waste management company can pick it up and that the company knows and acknowledges that waste was generated by suspected or confirmed COVID-19.
* The waste management company collecting must ensure that and treated and disposal is conducted at license waste treatment/ disposal facilities .
* All personnel or staff in contact with patients must be geared with appreciate personal protective equipment (PPE’s) at all times to prevent exposure or risk to health.
* Monitoring should be done at such facilities.
* All, bags, bins and boxes must be adequately sealed, as not to leak any fluids, and must be wiped down with 0.05% chlorine solution

Measures developed should consider the following.
* Develop a waste management plan following national guidelines and best practice standards for the disposal of medical waste (WHO, 2020).
* Establish procedures with medical waste service providers to regularly pick up the waste and dispose of this safely.
* Provision should be made for 5kg of solid waste per bed per day and this should be monitored and supplemented where it appears this may be inadequate.
* Ensure that access to waste is secure and controlled, for instance, by using lockable waste 1000l containers kept in a location that can only be accessed by health facility and nominated service delivery staff.
* Vermin control programs must be implemented throughout the site with HCRW collection points prioritised
* Provision for safe cleaning and disinfection of reusable containers should be provided. Cardboard, single-use HCRW boxes are removed from site and incinerated.
* Waste must not be allowed to accumulate or be stored inappropriate or unsecured containers.

== '''Engineering Services''' ==
Engineering services include patient services, ventilation, electrical power, water, medical gases, oxygen, compressed air, vacuum, lighting, and fire safety that support the needs of the patients and medical staff under normal and emergency situations. Good practice standards are provided in:
* IUSS Building Engineering Services<ref name = "IUSSBES">IUSS 2017, [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file]</ref>
* NHS Nightingale Instruction Manual<ref name="BDP2020">BDP 2020, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf]</ref>.
The guidance below draws on these and other manuals and standards. 

=== Building ventilation ===
==== Mechanical ventilation ====
While SARS-CoV-2 RNA has been detected in aerosol form, in experimental mechanical aerosolization studies, it is primarily spread through droplet and contact spread and the potential for airborne transmission is thought to be low.
However, the following advice is provided by ASHRAE regarding HVAC systems in general spaces (not specific to healthcare):
Effective high levels of ventilation must be achieved in the facility. Existing ventilation systems should be tailored to suit internal layouts and requirements and the following measures should be taken.
* Mechanical systems should be set to maximise fresh air supply to the facility. There should be no recirculated air without HEPA filtration or other validated decontamination processes.
* A pressure regime should be established, as shown in figure 2, to 'push' air from clean areas, to dirty areas and then out of the building.
* A clean air supply of over 10 L/s per person should be targeted for odour control.
* Fresh air supply shall not be located near patient beds to avoid drafts in winter.
* Extraction points can be located near patient beds in isolation wards or at a high level in long-stay wards. Short-circuiting of air between high-level supply and extraction is a performance risk in winter.
* Noise from ventilation systems and fans shall be below 45 dBA
* Protected lobbies, internal partitions, door arrangements, fans and extracts should be used to maintain the pressure regime and airflow as indicated in the diagram below.
 

[[File:Ventilation in temporary facilities.png|600px|thumb|none|Ventilation in temporary facilities<ref name="BDP2020"/>]]

==== Natural ventilation ====
The airflow direction between naturally ventilated zones may fluctuate according to the wind direction. This is not of concern within and between contaminated zones where occupants are either protected with mandatory PPE or confirmed to be infected with disease strains similar enough so as not be able to reinfect others. Where levels of occupant susceptibility to an airborne disease is significantly different, the less susceptible areas (such as PUI areas and uncontaminated areas) shall be protected from the naturally ventilated and contaminated areas by mechanical ventilation systems with a capacity sufficient to overcome the expected natural ventilation pressure fluctuations (typically 5-15Pa). Where such mechanical ventilation systems are not feasible or expected wind pressure is too great, zone adjacently must be avoided.

===Ultraviolet germicidal Irradiation===
The application of Ultraviolet Germicidal Irradiation (UVGI) for room air disinfection is well understood and is proven to be effective in the disinfection of microorganisms including M. tuberculosis (TB) in air. UVGI should, therefore, be considered as a valid element in indoor airborne infection control strategy for high volume settings. Studies have demonstrated the importance of good vertical air mixing in the room, and the safety of UVGI application. In areas where UVGI is indicated, the design and development of UVGI systems should be in accordance with the [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]<ref>van Reenen et al,2019 [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]</ref>

=== Electrical power ===
Sufficient and reliable power must be available at the facility for envisaged medical equipment, medical gases, lighting and building ventilation equipment. Power installations for the temporary facility can be divided into three zones as indicated below. These are existing services, the temporary service zone and services in each bay.
The following should be considered by competent engineering professionals.

=== Existing services ===
*Capacity: Evaluate whether sufficient power to accommodate envisaged medical equipment, additional lighting and heating, building ventilation and air conditioning can be provided. If existing capacity is insufficient, investigate if it is possible to route additional power from additional locations/transformers around the site or from adjacent sites.
* Safety: The existing electrical distribution network must be able to supply the required equipment load. If this is insufficient/appears unreliable, identify how this can be supported.
* Resilience: Evaluate back-up power and a UPS capacity against essential services demand. If existing capacity is not sufficient, source and establish temporary service capacity.

=== Temporary service zones ===
*Identify locations for temporary service zones where equipment can be located.
*Ensure that equipment and maintenance access is safe and easy.
*Ensure that all distribution boards, circuit breakers and cables are clearly labelled.
=== Services in each bay ===
*Provide pre-wired power strips/trunking as per bay requirements.
*Check that these include sufficient electrical outlets and service points for envisaged equipment.
*Ensure that trunking will carry required equipment loadings. The IUSS Building Engineering Services Guide can be used to check requirements<ref name = "IUSSBES"/>.

[[File:Layout_of_power_in_a_temporary_installation.png|600px|thumb|none|Layout of power in a temporary installation <ref name="BDP2020"/>]]
----

=== Water ===
Water points are needed for handwashing, showers and cleaning. The following issues need to be taken into account.
==== Supply ====
Onsite cold water storage, dedicated to the domestic water requirements of the facility, should be provided. A minimum usable volume of 500 litres per bed should be available.
Hot water storage and consumption should be confirmed by an engineer, as follows:
*Storage 25 L per bed.
*Consumption 180 L/bed.day W/O laundry; 250L /bed. day W laundry.

==== Handwashing ====
See infection control for clinical wash-hand basins
==== Showers ====
Showers for staff coming off shift should be available. Staff flow routes exiting contaminated treatment areas should pass through gowning and shower areas.
----

=== Medical gases, oxygen and vacuum (suction) ===
Medical gases, oxygen and vacuum services will be required in the facility. Mobile gas supply requires piping between supply and patient and clutter floor space. Preferably used fixed installations for patient rooms/cubicles, if possible.

System capacity and point of use pressures and consumption rates are to be ensured at all points. WHO provides technical guidance on [https://www.who.int/publications-detail/oxygen-sources-and-distribution-for-covid-19-treatment-centres oxygen sources and distribution]. 
[[File:Medical gas service layout.png|6oopx|thumb|Medical gas service layout<ref name="BDP2020"/>]]
The following points should also be taken into account.
* For centrally supplied medical gas and vacuum services, system resilience and availability must be ensured.
* Compressors, tanks, accumulators, VIEs, headers and controllers must be secured from uncontrolled access.
* Where possible, gas piping should be reticulated below floors or in ceilings to ensure protection from tampering, damage and ease of access.
* Where reticulation is within open areas, high-level reticulation with point-of-use droppers is advised. Low-level reticulation within rooms is to be avoided.
* Flexible piping can be used, ensuring it does not present a contamination or fire risk and should comply with local regulations. Special care should be taken with flexible O2 piping, keeping it to a minimum.
* Vacuum piping may be contaminated, where point-of-use filtration and collection systems fail. Precautions should be taken when demounting or disconnecting temporary vacuum lines.
* Ensure that oxygen pipelines are designed to provide sufficient flow to all oxygen points in the facility. In terms of utilities, oxygen and medical air would be required. A temporary vacuum point can be provided by mobile medical vacuum units distributed throughout the unit.
* Mobile medical air supplies should be considered where reaching piped specifications are not feasible. Where flexible hoses are used for oxygen and medical air special precautions need to be taken. Flexible oxygen piping must be chemically safe for O2 use. Where perishable flexible piping is used for medical air, terminal filtration at the point-of-use may be required at point-of-use. Especially for long-term use.
* Electrical and gas services can be reticulated against pipe racks or boards fixed to the bed-heads for head to head bed arrangements.
* Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.
* Gas service outlets to be labelled and colour-coded with 3mm lettering.
* SANS 7396-1 should be used to specify the requirements from design to commissioning of medical gas and vacuum systems.
* Medical gas and vacuum pipelines shall be marked per SANS 7396-1 and ISO 5359, as applicable.
* Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.
* SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.
* Plain-ended copper tubing for low-pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.
* Laboratory gas taps and valves shall be marked as described in SANS 10140-4.

=== Lighting ===
Existing lighting systems may need to be modified to suit the clinical requirements in the facility. High bay lighting presents inadequate colour rendering quality for the accurate detection or easy diagnosis of certain clinical conditions. This needs to be evaluated in the selection of supplementary lighting systems.
*Lighting levels should be provided in line with the indoor lighting levels recommended in the Table 6 of IUSS Building Engineering Services .
*Mobile task lighting systems may be adopted in the serious and critical stay wards to supplement incorrect lighting quality.
*Emergency lighting and illuminated emergency egress signage should be linked to the back-up power system.
*External security lighting in external parking areas and spaces around the building should be enhanced to ensure the security of medical staff who need to change shifts at night.

=== Fire safety ===
A functional fire alarm system should be available to support the patient care setting. Fire is a very real threat due to the possibility of an oxygen-enriched atmosphere developing so ventilation is crucial.
The use of temporary facilities for medical care should note the following fire risks (NHS, 2020):
*Patients may have a very high dependency.
*Areas are not specifically designed for patients and do not meet guidance on fire compartmentation and progressive horizontal evacuation.
*Large numbers of patients supplied with oxygen up to 10 litres per minute.
*Possibility of oxygen concentrations exceeding those generally found in the atmosphere- less risk if effective ventilation or large volume i.e. high ceilings.
* Possibility of storage, in excess of 40 litres, of alcohol-based chemicals (such as hand-rub), necessitating a flammables cabinet on site.
*Staff who may not normally work together .
*Staff who may not be familiar with the area.
*Staff not trained in fire safety, progressive horizontal evacuation or oxygen isolation for the specific area.
These factors should be taken into account in fire risk assessments which should then address significant findings in an action plan. Fire assessments should be undertaken by a qualified person and shared with operations and building management staff within the facility. Measures developed should include:
*An automatic fire detection system
*An emergency egress plans are prepared that include patients who have a very high dependency.
*Signage, notices and lighting are installed and are working effectively.
*Management processes are in place to minimise the risk of fire from ignition sources, fuels and oxygen.
*Staff are trained and a fire safety guide sheet for staff is developed and issued.
*Emergency egress routes are kept clear.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Additional Resources''' ==
=== [[Directory of Service Providers|A Directory of Service Providers can be viewed here]] ===

=='''References'''==
<references />

[[Category:COVID-19| ]]
[[Category:Alternate Care Sites|Alternate Care Sites]]

----
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19|(Return to Top)]] 
----

Infrastructure Guidance for COVID-19/Alternate Care Sites

2020-05-08T08:42:01Z

Peta: /* Structural integrity and operational responsibility */

[[Infrastructure Guidance for COVID-19|Return to Infrastructure Guidance for COVID-19]] 

== '''Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19'''==

This guidance work was initiated under the project titled: 
''Reducing Nosocomial and Community-Acquired Tuberculosis by Strengthening the Capacity of the South African Department of Health to Improve Implementation of Infection Control and Waste Management at All Levels of the Health System Under the President's Emergency Plan for AIDS Relief (PEPFAR)'' 

== '''Purpose and Approach''' ==
The global pandemic of COVID-19 caused by the coronavirus, SARS-CoV-2 is likely to result in a surge in need for medical care for Severe Acute Respiratory Syndrome (SARS) in South Africa. Considering the course of the pandemic in other countries, it is anticipated that South African hospitals will not have sufficient capacity to cope with the surge of persons requiring medical attention and that surge capacity via alternate care sites (ACS) will need to be established.
Surge capacity, contemplated here is not the frequent emergency department overcrowding experienced by healthcare facilities (e.g. Friday/Saturday night emergencies) or local casualty emergency that might overcrowd nearby facilities and have little to no impact on the overall healthcare delivery system. It is when a catastrophic event occurs and the affected population seek medical care from existing local healthcare facilities, causing healthcare infrastructure to become exhausted due to excess in demand. During a healthcare surge, the standard of care will shift from focusing on patient-based outcomes to population-based outcomes, and providers should anticipate “a shift to providing care and allocating scarce equipment, supplies and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals.”<ref>[https://asprtracie.hhs.gov/technical-resources/resource/491/altered-standards-of-care-in-mass-casualty-events Health Systems Research Inc., 2005]</ref> 

Surge capacity can be temporarily established in non-traditional environments, such as hotels, exhibition halls, community halls, and as field hospitals, on open spaces. 

In the context of this document, a quarantine site is a facility for patients who do not require continuous professional medical care, while an ACS is defined as a temporary facility that can provide continuous medical care for SARS. This document provides principles and considerations, high-level guidance for minimum requirements and examples for ACS. 

While an extensive set of health facility guidelines does exist<ref>[https://www.iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-servi IUSS Building Engineering Services (2017)]</ref>, these are applicable for conventional facilities and thus include services and guidelines that are not necessarily relevant to the treatment of a novel, highly infectious pathogen, with pandemic effects. Moreover, these do not provide well for the rapid and temporary establishment of facilities. 

In order to formulate high-level guidance, [[as invited by Business for South Africa]], the team reached out to professional industry bodies for inputs, in particular the South African Institute for Architects (SAIA), The Gauteng Institute for Architects (GiFA) [https://www.gifa.org.za/ Gauteng Institute for Architecture] and the [http://www.safhe.co.za/ South African Federation of Hospital Engineering (SAFHE)], by inviting input via a 36-hour research charrette. Relevant historical and contemporary literature was consulted, precedents identified and critically reviewed. An interaction with the team at Wuhan responsible for makeshift hospitals and emergency infectious diseases hospitals, Central-South Architectural Design Institute, was arranged with assistance of the Chinese Embassy. Material from the [[Infrastructure Unit System Support|Infrastructure Unit System Support (IUSS)]], international literature and guidance and input gathered from the broader architectural, engineering and healthcare professional communities was synthesised and moderated by the CSIR team. The draft was reviewed by an expert review panel. 
=== Acknowledgement of contribution ===
The contributions to the initial version of this were gratefully received. [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Acknowledgements|A list of these contributors can be viewed here.]]. 
New contributions are eagerly encouraged along with debate and discussion on the [[Talk:Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites|'''discussion forum.''']] tab above.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Scope and Assumptions''' ==
ACSs as discussed in this document are dedicated, temporary facilities for triage, testing, diagnosis, further referral and treatment of persons:
*suspected of having contracted SARS-CoV-2, (persons under investigation (PUIs)), who are symptomatic and/or are awaiting results,
*or are confirmed to be infected.
ACS will accommodate a variety of clinical, logistical, support and auxiliary services associated with the render of care. ACS will currently not be licensed to provide healthcare services. Since the ACS will operate in a non-healthcare facility, it cannot fully replace a hospital setting and its prime objective is to manage the patient load until the local healthcare system can meet demands. 

=== Exclusions ===
Quarantine facilities are accommodation facilities where a member of the community can remain for the duration of their isolation period. This is typically temporary housing for a cohort of people who do not need intensive medical attention but who cannot stay at home. Patients can take care of themselves and need limited monitoring by medical staff. Quarantine: Containing presumptive-case patients from each other and the general population.
Quarantine facilities – that is for asymptomatic persons who are in the community in self- or imposed isolation, but not displaying symptoms, or who are symptomatic, but are able to safely recover without clinical intervention and do not need continuous medical observation are not considered in this document.

=== Service regime ===
The following assumptions are made with respect to services under consideration.
* Temporary - limited to the part of the pandemic when the “conventional” hospital platform cannot meet demand. To be dismantled, thereafter.
* Uncomplicated, dedicated COVID-19 care is to be prioritised for ACS.
* Patients with comorbidities, paediatrics will be prioritised for conventional facilities, and only accommodated in ACS as a matter of last resort.
* 24 hour, 7 days a week operations. 

=== Assumed mechanism of transmission ===
Transmission of SARS-CoV-2 is understood to be from person to person firstly by [https://en.wikipedia.org/wiki/Transmission_(medicine)#Droplet_infection droplet] transmission, then by the [https://en.wikipedia.org/wiki/Transmission_(medicine)#Direct_contact contact] route and finally via airborne [https://en.wikipedia.org/wiki/Transmission_(medicine)#Airborne_airborne transmission] during or following mechanical aerosolisation. Water transmission risks are minor, occurring in special [https://en.wikipedia.org/wiki/Transmission_(medicine)#Fecal%E2%80%93oral Fecal-oral] circumstances. Reclassification of transmission mechanisms may nullify some of the approaches presented in this guidance. 

=== A call for strategic coordination ===
This document focusses on infrastructure requirements. These provisions are meaningless without staffing, equipping and resourcing. Whilst staffing, equipping and resourcing are not the focus of this document, these are likely to emerge as key constraining features. Resource constraints are likely to become acute during this pandemic. Doctors and nurses are already in critical short supply in South Africa and internationally, and are themselves susceptible to COVID-19 infection. Equipment and consumables are in short supply with heightened global demand, reduced manufacturing capacity and limits in trade flows. This necessitates strategic coordination, proactive planning, options appraisal and prioritisation. 

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Status Quo''' ==
=== Rationale and transmission status ===
According to the [https://en.wikipedia.org/wiki/World_Health_Organization World Health Organisation] (WHO), based on the largest cohort of COVID-19 patients, about 40% of patients with COVID-19 may have mild disease, where treatment is mostly symptomatic and does not require inpatient care. About 40% of patients have moderate disease that may require inpatient care; 15% of patients will have severe disease that requires oxygen therapy or other inpatient interventions, and about 5% have critical disease that requires the patient to receive mechanical ventilation. However, the evolution of the outbreak in some countries has shown a higher proportion of severe and critical cases and the need to rapidly increase surge capacity to prevent rapid exhaustion of biomedical supplies and staff. In some countries, doubling rates of cases every three days has been observed<ref>WHO-2019-nCoV-HCF_operations-2020, [https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf]</ref> 

South Africa has a high burden of disease, with a high prevalence of [https://en.wikipedia.org/wiki/HIV/AIDS_in_South_Africa HIV and TB]. Although evidence is yet to emerge of the effect of SARS-CoV-2 on a population with these pre-existing conditions, there is reason to proceed with caution<ref>The Conversation 2020, https://theconversation.com/tb-hiv-and-COVID-19-urgent-questions-as-three-epidemics-collide-134554</ref>. There is a potential direct and indirect benefit of ACS to people living with HIV and TB, as well as to general public health and the health system preservation. 

With the travel lockdown in place, and continued transmission, it appears that South Africa is on the cusp between cluster transmission and community transmission according to WHO’s classification, shown in the [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites#Key_clinical_and_infection_control_activities_for_different_transmission_scenarios_.5B3.5D|table below]], indicating that preparation should include temporary hospital facilities and mass critical care.

==== Key clinical and infection control activities for different transmission scenarios <ref>WHO 2020, [https://apps.who.int/iris/handle/10665/331492 https://apps.who.int/iris/handle/10665/331492]</ref> ====
{| class="wikitable"
|-
! !! '''No Case''' !! '''Sporadic Case''' !! '''Clusters of Cases''' !! '''Community Transmission'''
|-
| Faculty Space, Including for Transmission|| Usual Space. Enhanced Screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards). || More patient care areas re-purposed for COVID-19 within the health system, especially for severe cases || Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Staff|| Usual space. Enhanced screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards)||More patient care areas repurposed for COVID-19 within the health system, especially for severe cases||Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Supplies||
*On-hand supplies. Equip wards for COVID-19 treatment.
*Identify essential equipment and supplies, including oxygen.
*Prepare expanded local supply chain
||
*Expanded inventory of supplies with detailed protocols for use.
*Activate expanded local supply chain.
*Prepare national supply chain.
||
*Conservation, adaptation, selected re-use when safe.
*Activate contingency planning and procurement for essential equipment and supplies.
*National supply chain.
*Prepare expanded supply chain at the global level
||
*Activate contingency planning should critical equipment be in short supply.
*Determine allocation of lifesaving resources for HCWs and patients.
*Activate expanded global supply chain
|-
| Standard of Care|| Usual care with enhanced awareness and recognition of immediate needs for first COVID-19 patients|| Usual care and treatment for all patients, including those with COVID-19||Identify context-relevant core services. Shift service delivery platforms. Consider reduction in elective patient encounters, including elective surgical procedures.|| Mass critical care (e.g. open ICU for cohorted patients).
|-
| Care areas expansion|| No requirements for expansion|| Designate 10 beds per suspected COVID-19 case|| Expand COVID-19 patient care areas by a factor of 35 ||Expand COVID-19 patient care areas by a factor of 58
|}

=== Quantification of need ===
At this time there are various parallel initiatives aimed at forecasting the South African epidemic, quantifying the projected need for facilities, and a shortfall in existing capacity. At this time, there is no consensus on this. This section will be updated as further data becomes available.
ACS will prioritise mild to moderately affected COVID-19 patients where basic, targeted medical care will be provided. Should patients’ needs evolve, requiring escalation of care, then the transfer of patients from ACS sites to conventional sites of care will be needed as a matter of course, bringing with it logistical challenges and risks. In the event that the conventional hospital platform is unable to cope, ACS will have pressure to provide care for severe and critical patients, and finally for patients with comorbidity and special requirements, such as paediatrics, persons living with HIV (PLHIV), TB patients and pregnant women. The following pragmatic approach, aligned with the WHO recommended strategic approach, is suggested.
*ACS should preferably be identified with space for expansion.
*The set-up should be done so that levels of care can be upgraded to higher levels of uncomplicated care.
*A secondary upgrade for more diverse package of care may become necessary.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Strategic Approach''' ==
According to WHO, clinical interventions must be put into place immediately and then scaled up according to the epidemiologic profile.
[[File:COVID-19 Resource allocation.png|none|thumb|600px|right|WHO Strategic approach to clinical care]] 
Under this declared state of disaster, the clinical care strategy which cannot be accommodated within existing facilities, can, on a temporary basis be hosted in ACS:
*Within and around existing healthcare facilities, via reconfiguration and/or augmentation.
*In existing non-healthcare buildings suitable for repurposing, such as universities, hotels and conference centres, warehouses, gyms, hostels etc.
*On open fields, including paved parking areas with rapidly constructed, dismountable structures, such as modular tented structures or using rapid modular construction techniques. 

ACS will provide isolation, general (non-acute) care for patients with mild to moderate symptoms and as required, acute care for patients with severe symptoms. Containing confirmed-case patients from general population. Confirmed-case patients can be housed together en masse, while presumptive-case patients must be individually quarantined.
As shown in the WHO Strategic approach to clinical care, the WHO recommends a range of services to meet patient need (''Citation needed''). General (non-acute) care ACS model is designed for minimal acuity patients requiring minimal activities of daily living support (e.g. COVID-positive with minimal symptoms or require <2L of oxygen). Acute care ACS model is designed for higher acuity patients requiring closer monitoring or respiratory support (e.g. COVID-positive with pneumonia or respiratory distress requiring ventilator support). Paediatric patients are to be accommodated in separate wards, where strictly controlled visitation may be allowed. 
As a preliminary estimate, the following ratios of service is proposed:
[[File:COVID Ratios of Service.png|none|thumb|600px|center|COVID Ratios of Service]]

{| class="wikitable"
|-
! '''Case severity, risk factors<ref group="Notes"> Test suspect COVID-19 cases according to diagnostic strategy</ref><ref group="Note"> Known risk factors for severe COVID-19: age over 60 years, hypertension, diabetes, cardiovascular disease, chronic respiratory disease, immunocompromising conditions.</ref>''' !! '''Recommendations'''
|-
|Mild || Patient should be instructed to self-isolate and contact COVID-19 information line for advice on testing
and referral.
|-
|Moderate, with no risk factors ||Test suspected COVID-19 cases according to diagnostic strategy. Isolation/ cohorting in:
* Health facilities, if resources allow;
* Community facilities (e.g. stadiums, gymnasiums, hotels) with access to rapid health advice
(i.e. adjacent COVID-19 designated health post/EMT-type 1, telemedicine)
*Self-isolation at home according to National guidance
|-
| Moderate, with risk factors || Patient should be instructed to self-isolate and call COVID-19 hotline for emergency referral as soon as possible
|-
|Severe || Hospitalization for isolation (or cohorting) and inpatient treatment.
|-
|Critical|| Hospitalization for isolation (or cohorting) and inpatient treatment.
|}

=== Notes and References: ===

<references group = "Note" />
<references />

=== Typology dictates & case studies ===

[[File:NHS Nightingale Hospital London.png|thumb|NHS Nightingale Hospital London <ref name="NHS Nightingale Hospital London">Coronavirus: Building NHS Nightingale Hospital London, 2020 [https://www.bbc.com/news/in-pictures-52092253 https://www.bbc.com/news]</ref>, ]]
To meet the requirements set out in this guidance, prospective “host” sites should be carefully evaluated. The type of “host” site selected will strongly influence or dictate the choice of ACS service model.

No site is likely to meet all requirements and recommendations set out in this document. Adaptations and compromises will be necessary. Services should be provided on site where it is pragmatic to do so, for example where similar services are provided. Outsourcing can also be practical/feasible for some services, such as laboratory services, catering and laundry, provided suitable logistical arrangements can be made.

Some typological responses and service models are set out in precedent examples, shown below. The examples demonstrate that a variety of host settings are workable, provided that the appropriate utility can be contrived.

=== Pragmatic approach ===
Other than in metropolitan areas, co-location of ACS on the premises of, or adjacent to existing healthcare facilities will often be preferable because this is where intensivists and specialist clinical staffing will be available, and support services may be well established. Nevertheless, augmenting capacity at existing facilities should take into account current workloads and capacity to ensure that the COVID-19 surge disrupts normal service provision as little as possible, including continuity of care for patients with chronic conditions and TB and HIV patients. 

*'''[[Infrastructure Guidance for COVID-19/Alternate Care Sites/Case Studies|SARS ACS Precedents and Case Studies can be found here]] '''

=== Notes and References ===
<references />

== '''ACS Infrastructure Planning''' ==

=== Establishing a team ===
A planning team should be formalised to establish the minimum planning and operational requirements for the ACS and to liaise with the local community. The team should include individuals with expertise in the following areas (ideally with knowledge of healthcare delivery under emergency conditions):
*Disaster response / emergency management coordination,
*Clinical care and staffing,
*Infection Prevention and Control practitioners must be involved in all stages of planning, commissioning, in-use, and decommissioning of the facility
*Facility set-up, operations and management,
*Security,
*Transport (patient, staff),
*Engineering and project management,
*Procurement and coordination of supplies, equipment and pharmaceuticals, and
*Community liaison to ensure that concerns of the adjacent population on understood an addressed.
It is important to ensure compliance with health, safety and building regulations, by ensuring the involvement of relevant local authorities. Stakeholder engagement should be formally documented. Concerns and grievances should be systematically addressed.

=== Structural integrity and operational responsibility ===

'''Structural modifications:''' ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered. 

'''Competent person:''' All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed. 

'''Asset responsibility:''' Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented. 

'''Integrity and responsibility'''

'''Structural modifications''': ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered.

'''Competent person''': All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed.

'''Asset responsibility''': Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented.

'''Decommissioning''': Decommissioning of the facility shall be assigned to the competent person discussed above. All residual structures upon decommissioning shall comply with the National Building Regulations. Upon decommissioning, removal of equipment shall be the responsibility of the owner. An infection prevention and control practitioner should be engaged in the decommissioning phase to oversee terminal cleaning and disinfection of equipment and premises.

'''Closure''': Once all patients can be safely discharged or transported back to existing facilities for continued care and there are no ongoing healthcare surge capacity needs, the ACS can be closed. Shut down of an ACS will require decommissioning, identification of new homes or storage for equipment, and termination of ongoing contracts or arrangements. Shut down should be expedited so that the facility can quickly be returned to the control of the existing owners and returned to its usual function.

Action checklist items for ACS closure should include, but not be limited to, the following:
*conduct a site walk-through with the facility owner when shutdown activities are completed to ensure that terminal cleaning and disinfection of supplies and premises, removal of equipment and supplies, and other surge closure activities have been completed to the owner’s satisfaction.
*perform medical records storage procedures.

== '''Site Selection''' ==
When selecting a site, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital can be utilised to determine whether the site is suitable for a 100, 1000 or 2000 bed facility, as required. The following indicative minimum site sizes are needed:
*100 Bed ACS/ hospital conversion, requires ± 4 300 m2
*1000 Bed ACS/ hospital conversion, requires ± 17 600 m2
Evaluation should be done by examining plans (if available), satellite images, drone images, scans and by physical inspection (walkabout). A comprehensive photographic survey should be undertaken and retained for record purposes on the site inspection. This will serve as an audit record and may assist in returning the site to its original function on ACS decommissioning and closure. When scrutinising documents and conducting site inspections to confirm the suitability of a site to host an ACS, the following criteria should be taken into account.
=== Criteria ===
*Affordability (costs, including operational costs known and budget identified),
*Sufficient physical space and capacity to house the immediate need, with the potential to accommodate physical space requirements. For example, open site should not be sloping,
*Legal rights and encumbrances, including renewal opportunity,
*Good access to highway and main roads,
*Well secured perimeter and limited controlled access points,
*Proximity to other hospitals and care sites,
*Accessibility for key staff and public transport,
*Good vehicular access around the site to set up temporary equipment such as back-up generators,
*Free from clear and present danger,
*Outside attenuation zones, floodplains,
*Outside high wind zones,
*Structure in good repair,
*Effective onsite facilities management team who understand how systems work,
*Potential for expansion, if required,
*Access to sufficient capacity for
**potable water,
**adequate sewage,
**telephone,
**internet access with sufficient bandwidth,
**electricity,
*A zone for cleaning, disinfection, and decontamination of equipment at least 15 metres away from occupied areas with access to water, a hard impervious surface and drying areas in the sun, with runoff discharge into the sewer and not into marine ecosystems or the environment. Include area for cleaning and storage of cleaning equipment.
*Likelihood of acceptance of hosting an ACS by the adjacent and local community

=== Desirable ===
*Durable, cleanable surfaces,
*Large open spaces that can be converted to accommodate temporary structures,
*Good ventilation,
*On-site kitchen and laundry,
*Housekeeping staff (chemical and equipment storage, lockers, rest facility, administration office),
*Space conducive for staff respite area and locker rooms,
*Amenities with universal access,
*Fire protection safety and equipment,
*Elevator access for patients if the building has more than one floor,
*Capacity for expansion, and
*Accessible to at least two roadways to provide continued access in the event that one roadway becomes blocked on inaccessible.

== '''Infection Prevention and Control''' ==
General guidance for COVID-19 [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|Infection Prevention and Control]] can be accessed [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|here]] 

Infection prevention and control in the context of COVID-19 should respond to transmission routes of primary concern for the pathogen of interest (droplet and contact transmission, and management of risk waste) as well as infection risk of a general nature (water and sewerage, airborne transmission – under high TB/HIV burden, and general waste).
In addition to satisfying [https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html standard precautions for all patient care], transmission-based precautions should focus on three pillars: exposure reduction by spatial configuration, operational strategies, and personal protection.
=== Transmission-based precautions ===
'''Droplet and contact spread''': Transmission of SARS-CoV-2 virus occurs via droplet and contact spread. The virus has been shown to persist on surfaces for extended periods of time and is known to be efficient at infecting people. 

'''Medical waste and linen:''' As SARS-CoV-02 is carried in body fluids and faecal matter, disposal of contaminated items (tissues) and cleaning regimes (spaces, garments, linen) should be accommodated carefully in the workflow design and infrastructure provision. A site-specific waste management plan should be formulated in accordance with a site-specific waste management plan with reference to SANS 10248. 

'''Airborne transmission:''' Under exceptional circumstances, the risk of airborne transmission arises for SARS-CoV-2, as detailed below.
{| class="wikitable"
|-
!Airborne Transmission Risk Factors
|-
|
As SARS-CoV-2 is not considered airborne, respiratory protection against airborne transmission is not considered necessary, except where aerosolisation of particles may be a risk.
According to the CDC
*tracheal intubation,
*non-invasive ventilation,
*tracheotomy,
*cardiopulmonary resuscitation, or
*manual ventilation before intubation and bronchoscopy.
According to doctors in the field also when performing
*COVID-19 diagnostic sampling as patients can be induced to cough and sneeze.
*Suspected or confirmed comorbidity of TB is not an additional risk where correct COVID-19 PPE is applied.

|}
South Africa has a high prevalence of TB and HIV, and therefore, although the risk of COVID-19 transmission via the airborne route is not paramount, there is a high likelihood that undiagnosed TB infectious patients may present at the ACS for treatment. TB triage may be challenging in the ACS as there are symptoms in common (coughing) with COVID-19. This country-specific risk is taken into account in this guidance

=== Additional precautions ===
'''Water and sewerage contamination:''' The International Water Association [[Infrastructure Guidance for COVID-19/Alternate Care Sites/COVID-19 A Water Professionals Perspective|concluded]] that water and sewerage contamination is not considered to be a key risk factor for COVID-19. The panel expressed concern for “how waste and specifically wastewater (medical) would be handled by places (e.g., hostels, hotels) that are used to serve as interim COVID-19 quarantine or testing facilities or accommodation ([ACS]. These are places other than hospitals that are used in the interim for such purposes and do not usually handle wastewater from medical settings. Such facilities should be monitored carefully.” 

== '''Spatial strategies for infection prevention and control''' ==

=== Restricted access and zone control ===
The site will be arranged to establish clear zoning, with a clear restricted zone protocol and access protection. Zones should be deemed to be "contaminated" or "uncontaminated" with clear transition areas between them.

; Contaminated zones
: (also known as "dirty areas") are areas occupied by COVID-19 infected persons, PUIs, equipment, materials and supplies which have come into contact with such persons without yet undergoing a decontamination procedure. These areas will include patient ward areas and ablutions, patient admissions (including ambulance drop-off) and the associated clinical areas. Staff rest and dining facilities should be outside the contaminated zone. Limited stock for immediate use should be kept in the contaminated zone. Layout designs should consolidate contaminated zones as far as reasonable, and avoid uncontaminated zones as islands in contaminated zones.

; Uncontaminated zones
: (also known as "clean areas") are areas not generally occupied by PUIs or confirmed COVID-19 infected persons. Equipment, materials and supplies in these areas have not yet come into contact with contaminated zones or have undergone a decontamination procedure. These will include clinical management planning rooms, stock rooms, bulk stores, pharmacy, laboratory areas, kitchen and laundry.

; Transition zones
: (also known as intermediate zone) are the spaces through which transfer of people and goods from uncontaminated to decontaminated zones, and vice versa, occur. Materials from the contaminated zone should be decontaminated or contained in the transition zone. The transfer of goods and persons should be highly ritualised and, as far as possible, traffic across transition zones should be minimised. Transition areas should be strategically located to serve this function. Separation of in-going and out-going transfer of goods and persons is preferable. Transition areas include ambulance, trolley decontamination, CSSD, laundry and waste bagging areas, patient locker area and staff change areas with spaces for donning and doffing of PPE.

=== Site layout and master-planning ===
Spatial configuration and layout can ensure unnecessary cross-over of function is avoided. This entails the systematic separation of functions and the managed transition between activities to facilitate consistency of care, an orderly, efficient work environment, less waste and reduced risk for improved outcomes. To achieve this, functional relationships should first be considered at the site level before being considered at the building level. 

<gallery mode=packed heights=300px style="text-align:left">
Layout for a SARS facility, clustering functions with minimised cross-over.png|center|thumb|Layout for a SARS facility, clustering functions with minimised cross-over <ref name="Layout1">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Layout_for_a_Patient_cohorting_strategy.png|center|thumb|Layout for a Patient cohorting strategy <ref name="Layout3">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Tygerberg Hospital virus triage unit site layout.png|center|thumb|Tygerberg Hospital virus triage unit site layout <ref name="Western Cape Provincial Government, 2020a">Western Cape Provincial Government, 2020 a</ref>
</gallery>

The WHO's Clustering Layout <ref name="Layout1"/> and Tygerberg Hospital virus triage unit<ref name="Western Cape Provincial Government, 2020a"/> show worked examples of building and site layouts, which are configured with these principles, respectively. '''Cohorting''' is defined as clustering patients with similar or compatible clinical needs together for risk reduction, acuity, efficiency and quality management, as illustrated in WHO's Cohorting Layout <ref name="Layout3"/>

=== Workflow ===
Within individual functional zones, the workflow activities can be arranged to proceed from clean procedures to contaminated procedures. In the example below, the staff arrival, PPE donning, doffing and patient flows are worked to have controlled interaction and minimised cross-over

<gallery mode=packed heights=400px >
ACS HCW Flow.png |ACS Health Care Worker Flow
COVID-19 Workflow in small unit.png |COVID-19 Workflow in Small Testing Unit <ref name="Western Cape Provincial Government, 2020b>Western Cape Provincial Government, 2020 b</ref>
COVID-19 Workflow in large unit.png |COVID-19 Workflow in Large Testing Unit <ref name="Western Cape Provincial Government, 2020b"/>
</gallery>

As far as possible, a single direction flow of clean to dirty is recommended for all processes: support services, supply and waste.
The Small ACS unit workflow diagram<ref name="Western Cape Provincial Government, 2020b"/> illustrates the recommended separation of access and exit, separate waiting seats, for persons who may be COVID-19 infected. Separate spaces are provided for donning and doffing PPE. Staff change areas are provided.

In the Large ACS unit workflow diagram <ref name="Western Cape Provincial Government, 2020b"/>, there is a clear separation between staff areas and patient areas. Waiting seats are set far apart to reduce transmission risk. Staff change rooms are provided near the point of entry to the facility for staff to change from street clothes into medical work clothes. To prevent work clothes worn inside the facility from contaminating street clothes, these are kept in separate lockers. A step-over barrier from dirty to clean sides of the change room is helpful to enforce a mind-set of avoiding cross-contamination. Bins for contaminated garments are to be provided in change rooms. Shower facilities are to be provided for staff.

== '''Operational Strategies''' ==
=== Cleaning, disinfection and decontamination ===
Surface and substrate specification, and detailing of all areas should, as far as possible, allow for frequent:
*Cleaning with detergent and water.
*Disinfection with 75% alcohol solution (metal surfaces).
*[https://en.wikipedia.org/wiki/Sodium_hypochlorite Sodium hypochlorite] (1,000 ppm)/ Household bleach.
*Disinfectants listed on the EPA List N<ref>The United States Environmental Protection Agency, [https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 List N: Disinfectants for Use Against SARS-CoV-2 (Last Visited 2020) ]</ref> (for non-critical environmental cleaning).
*High-intensity ultraviolet surface disinfection (UV-C).
*Decontamination and sterilisation of clinical equipment.

=== Goods and waste management ===
Remove any unnecessary furniture, equipment and paraphernalia from all patient care and clinical areas. Provide a clear, secure space for waste management. Any potentially infectious waste materials generated at the ACS should be considered and treated as medical waste (health care risk waste). The applicable legislation is:
*[https://www.gov.za/sites/default/files/gcis_document/201409/35405gen452.pdf The National and Provincial Health Care Risk Waste Management Regulations].
*[https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf National Department of Health COVID-19 Environmental Health Guidelines.]<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>
Waste disposal bins should be positioned near the exit inside each patient rooms or wards to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another patient in the same room.

=== Materials and finishes ===
Floor materials must be:
*Level,
*Free of dust and oil,
*Impervious and smooth,
*Slip-resistant in wet areas (e.g. patient ablutions).
Smooth, cement screed floors are acceptable. Where hosting facilities have carpeted areas, a risk assessment of factors such as durability, hygiene and decontamination needs to be conducted. In cases where the acceptance of carpeted flooring is contradicted (but other factors make it a compelling option), temporary floor finishes or covering can be investigated.

== '''Personal protection''' ==
=== Hand sanitation ===
Where wash-hand basins are not provided, clinical wash-hand basins should be installed, at the minimum rate of provision of one wash-hand basin per 5 beds. Clinical wash-hand basins (see figure below) have a variety of features not present in standard wash-hand basins, which are preferable for infection prevention and control. Where standard wash-hand basins are provided, an upgrade is not necessary. In all cases, there should be no surfaces and no clutter, equipment or supplies in the vicinity of wash-hand basins, including surgical gloves.
<gallery mode=packed heights=400px>
Clinical hand wash basin.png|Handwash Basin <ref>de Jager 2020</ref>
Portable Wash-hand Basin.png|Portable wash hand basins can be provided in ACS <ref name="BDPa">BDP 2020, NHS nightingale instruction manual, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf</ref>
</gallery>

Where wash-hand basins are not available, portable units can be used, as shown above<ref name="BDPa"/>. Mounted brackets for hand sanitisers are to be provided for every two beds, preferably mounted near the foot rather than the head of the bed and at all common touch points such as entry points at ablution facilities, linen room, sluice, storerooms, medicine rooms/cupboards, near refrigerators, telephones, light switches, at entry/exit doors, etc.

=== Personal protective equipment ===
Donning and doffing points for personal protective equipment, and convenient, safe disposal of consumables to be placed at critical key points when entering patient areas.
----

== '''General transmission mitigation''' ==
=== Water and sanitation ===
To comply with National Building Regulations; Hazardous Biological Agents Regulations and National Department of Health COVID-19 Environmental Health Guidelines<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>.

=== Droplet aerosolisation ===
When designating areas for procedures during which aerosolization and airborne transmission risk is high, the building ventilation must be carefully considered to take into account downstream risks. In particular, consider to where potentially contaminated air, arising from aerosol-generating procedures, is exhausted. In general, air exhausted directly to the outside is diluted and considered safe, unless there are openings to occupied spaces near the exhaust air outlet. 

In the event that potentially occupied spaces will receive partially diluted or undiluted contaminated air, or where this is indeterminate, the aerosolising activity should be designated to an alternate area. In the event that an alternative is not available, some treatment regime (air filtration or air disinfection) is necessary. 

In most naturally ventilated settings, the airflow direction between zones may fluctuate according to the wind direction. Such high-risk spaces should not be adjacent to spaces with high susceptibility rates, such as PUI areas and uncontaminated areas. Contaminated areas should not be directly adjacent to clean areas unless mechanically ventilated. 
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|Guidance on COVID-19 building ventilation design is provided here]].

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Health, Safety and Well-being''' ==
In addition to the infection prevention and control measures discussed above, the following should be provided for health, safety and well-being.
=== General provisions ===
*Minimised and controlled entry and exit points, with suitable control.
*Clearly identified accessible and marked routes for patients, staff, goods and waste.
*Clear designation of restricted zones.
=== Site level provisions ===
*Safe staff parking and arrival of staff via planned and public transport.
*Clearly demarcated parking for people with disabilities.
*Arrival and departure point for patients via public transport, passenger vehicles, and emergency service.
*Limited safe patient parking.
*Supply of goods and removal of waste.

=== Within and between buildings ===
*Entrances with a clear opening width (CoW) of at least 900mm.
*Routes with a minimum width of 2 000mm free of hazards, for example, rubbish bins.
*All clinical, patient and support areas to be accessible by trolley.
'''Ramps''' should be of stable construction, capable of sustaining a mass of 300kg. They should incorporate side lips and the surface should be slip-resistant. Gradients should be as gentle as the circumstances allow. (Recommended maximum 1:20). 
'''Small changes in floor levels''' are not desirable, but where these exist are to be clearly marked with reflective paint/ tape, and lit at night
Elevators between different floors, where patients need access (The recommended minimum lift size for patient trolley/stretcher movement is 1 400mm × 2 400mm, however, this may not be possible). 
'''Pathways''' to be lit at night, where used at night. 
'''Staircases''' must be well-lit at night with non-slip surfaces and secure balustrades. 
'''Doors''', Double doors and automated or push-operated doors to all clinical areas are to be preferred, where these are newly installed or able to be retrofitted. Door closers are to be disabled, where not necessary to reduce touch surfaces. Hand sanitisers to be provided at where high touch common surfaces occur (e.g. wall-mounted at doorways).

=== Signage ===
The appropriate level of information to facilitate legibility, orientation and wayfinding. Minimum standards, signage to be:
*Clearly visible, simple font, font size, contrasting colours, placed in the field of vision
*Washable
*Comprehensive safety signage - fire signage (exits, equipment etc.)
*Restricted areas clearly marked
*Identification signage - each patient space to be allocated a unique number and a whiteboard or perspex sheet for writing the patient’s name
Signs should be posted immediately outside of patient rooms indicating appropriate IPC precautions and required personal protective equipment (PPE).
Signage of a temporary nature can be provided on laminated white A4 sheets attached eye-level. The text should be black sans-serif (for instance Arial) text at least 40point size and centrally positioned on the sheet. Detailed guidance on signage is provided in IUSS Inclusive environments.
=== Safety and security ===
Upon identification of the ACS host site, a team should be convened to conduct a multidisciplinary safety and security analysis. These critical team members need to form the working committee responsible for undertaking the detailed assessment of the existing facility’s security. They should analyse data about the security system’s condition and review existing security concerns or issues that are reasonably likely to become concerns in the near future. The figure below represents a five-zone approach to security, which is a recommended, systematic approach to security.
[[File:Zonal approach to security.png|center|600px|thumb|IUSS Security- Zonal Approach to Security <ref name="IUSS Security">IUSS Hospital design principles - Security [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file]</ref>]]
The security strategy should take into account that whilst clinical services and some logistical and support services will be required 24 hours a day, seven days per week, some support services, logistics services and auxiliary services may only be operational for the minimum periods required to meet demand. These functional elements should be capable of being secured, for example over weekends and at night, as the case may be.
Detailed guidance is available in [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file IUSS Hospital design principles - Security] <ref name="IUSS Security"/>

=== Comfort and dignity ===
Supplemental heating: Patient health and comfort are dependent on, amongst others, maintaining body temperature. The ACS structural technology must be selected to achieve the general indoor environment conditions discussed in a subsequent section for all clinical and occupied areas. As we are moving into South African winter supplemental heating may be required, especially in the evenings, in order to avoid hypothermia. Use of fans, bar, radiator or gas heaters should be prohibited. Unless clinical areas can be maintained above 18 degrees centigrade, patients should each have an infrared heater available, in addition to blankets. Personal/ donated blankets can be considered if they are laundered first and could be destroyed upon discharge.
Mobile screens should be available to provide privacy where necessary (e.g. during consultations or procedures).
<gallery mode = packed heights = 400px>
Bed_Isolator_-Vietnam.png|thumb|Flexible Barrier Isolator<ref>WHO. (2020), Severe Acute Respiratory Infections Treatment Centre. Geneva, Switzerland : WHO- World Health Organization</ref>
ACS Cohort beds.png|ACS Cohort beds.png|thumb|Excel Centre London 04-2020 <ref>Architects' Journal 2020, [https://www.architectsjournal.co.uk/news/nhs-nightingale-bdp-on-the-first-nine-days-converting-the-excel-centre/10046749.article https://www.architectsjournal.co.uk/news]</ref>
</gallery>
Some solutions which address patient privacy and dignity are depicted above.

=== Notes ===
<references/>

== '''Schedule of Accommodation''' ==
Based on clinical needs of the ACS, a schedule of accommodation can be crafted capturing the clinical, clinical, logistical, support and auxiliary services associated with the render of care. When deriving a schedule of accommodation, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital tool can be used. Functions to be accommodated are: 
'''Clinical services''': Triage, rapid assessment of persons entering the facility, to expeditiously identify and render the appropriate service. Admissions and registration. Inpatient accommodation is to be organised according to cohorting principles, discussed above. Testing and diagnostics, including laboratories and x-ray. Safe storage and dispensing of drugs to patients.Offices for clinical administration and clinical planning meeting rooms in the clean zone are needed. 
'''Logistical services:''' Logistical services will entail management of flows of people, goods, services and information to and from the site, as well as within the site. It includes security and communication arrangements. Staff entry, preparations to transition from outside to clinical work environment, including pause areas for relief. Emergency services, visitors. Goods, supplies and storage and waste removal and/ or treatment.
Support services key to the provision of clinical services should be separated so that the risks associated with that particular activity can be managed. 
'''Support services are:'''
*Laboratory services
*Catering
*Laundry
*Environmental cleaning and housekeeping
*CSSD
*Maintenance and cleaning of surrounds, eg. waste areas
*Porters/”runners”, stretchers/wheelchairs
*Mortuary
* Security
Support services can be provided off-site, in which case, safe, secure and efficient transfer and logistical arrangements should be designed. 
'''Auxiliary services:''' Auxiliary services are services which may be provided on or near the ACS site, but which are not directly related to core clinical care. This included overnight accommodation for staff who may not wish to return home to avoid exposing their families, or who need rest between shifts, or for discharged patients awaiting transport home, volunteers who have recovered from SARS-CoV-2.
Limited psychosocial services and allied health services may also be provided on or near ACS for example by approved partners.
Examples of schedules of accommodation for patient and support spaces for a protective isolation ward is available [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedule for COVID-19 Isolation Wards|here]] and mild to severe cases [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedules for COVID-19 Wards for Mild to Severe Cases|here]].

== '''Clinical Services''' ==
=== Triage ===
Confirmed COVID-19 cases and PUIs who are referred from a testing facility or a higher level of care, will enter the facility in a triage area to receive vital screening and initial assessment. They will be registered and admitted to inpatient care. They will be assigned a "ward" or section of the facility - based on disease status and acuity. These are Protective Isolation, the Mild & Moderate ward, or the Critical & Severe wards. Patients should be clustered according to gender. As far as practicable, ablutions for each gender, isolation patients, paediatrics and staff shall be separately provided. Paediatrics patients, if admitted, are to be assigned a dedicated section.
As patients recover or deteriorate, they may be relocated to the appropriate section/ ward.
Once the patient has sufficiently recovered and a negative test result is received they will be appropriately decontaminated and discharged, collecting medication from the dispensary on exit. Patient movement between various sections of the ACS will be restricted as far as possible, with mobile radiology units, in-ward medication dispensing and in-ward food service.

=== Inpatient ACS accommodation ===
Separate spaces for:
*suspected, unconfirmed cases, under observation (PUIs), to be accommodated in isolation facilities (separate rooms, if possible);
*patients with confirmed COVID-19 with mild to moderate disease, not requiring dedicated oxygen therapy;
*patients who require dedicated oxygen therapy;
*patients requiring mechanical ventilation; and
*recovered/ confirmed negative.
==== Protective Isolation Facilities ====
Suspected, unconfirmed cases, under observation – persons under investigation (PUIs) to be accommodated in protective isolation facilities (separate positive-pressure rooms, if possible). PUI are restricted to their rooms. All food and laundry services will be brought to the PUI rooms to reduce interaction and potential contamination. All waste will be collected by facility staff and taken to waste handling areas. Infection prevention and control measures are put in place for the handling of used food utensil and laundry as well as waste collection. PUI areas will have restricted access, including for staff serving other inpatient sections, for confirmed cases.

==== Inpatients accommodation for confirmed COVID-19 ====

Inpatient facilities confirmed positive COVID-19 can be accommodated in large shared ‘wards’ with partitioning between patients. Partitioning between patients is optional. Partitioning is preferable to curtains found in conventional hospitals, as they are more conducive to daily cleaning. If curtains are used, antimicrobial treated fabrics with biocide used to treat the curtains has been tested to international standard EN 14476 and shown to be effective against H1N1 Influenza A Virus (Swine Flu), >99.999% kill rate in 5 minutes and measles morbillivirus, >99.99% kill rate in 5 minutes are preferred. If only separate rooms are available, patient monitoring and surveillance will need to be accommodated. This phase of treatment has a lower area/space requirement compared with PUIs, as cross-infection between patients is less of a concern. Shared ablution facilities are acceptable. It is recommended that, at least, two general accommodation ward areas be provided. 

a) Mild and moderate patients, and 
b) Serious and critical patients. 

The room must have openable windows for natural ventilation if a dedicated positive pressure ventilation system is not available. Ducted ventilation systems shall not be shared between PUI areas and confirmed COVID-19 patient areas. 
[[File:COVID-19 ACS - protective isolation – bed layout.png|thumb|center|800px|ACS - protective isolation – bed layout]]
[[File:COVID-19 ACS – mild-moderate patient bed layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient bed layout]]
[[File:COVID-19 ACS – mild-moderate patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient shared ward layout]]
[[File:COVID-19 ACS – severe-critical patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – severe-critical patient shared ward layout]]

Examples above show bed layout with bed spacing for protective isolation, a mild/moderate patient and a mild/moderate patient shared ward and for a severe/critical patient

=== Patient services ===
Patients in ACS will not generally be ambulatory and will be confined to their room, or cubicle in a bed. In general, domestic beds or hospitality industry (hotel) beds are not suitable for patient care. These should only be used where a hospital-grade bed cannot be sourced, as hospital beds are designed for ease of cleaning and decontamination (for infection prevention and control) and with patient and ergonomics, safety and comfort taken into account (they prevent back injury for nursing staff and can help to prevent bedsores). The higher the specification of bed, the more suitable it is for the higher levels of care. Lockers for patients personal belongings should be provided in the uncontaminated zone (in which case bedside lockers will not be necessary), and it is preferable (where bedside lockers are not provided) for overbed tables to be provided, per bed, if possible. 
The following beds are suitable:
*Repaired and refurbished beds from condemned hospital stocks.
*South African National Standard, SANS 521:2013 Edition 3.5, on Hospital beds and cots ISBN 978-0-626-28830-3.
*Beds listed on the National Treasury (See [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Hospital Bed Specification|specification]]).
The table below details the minimum services required at each patient bed. Details on these services are discussed in a subsequent section of the document.

{| class="wikitable"
|-
! Service/ Capacity!!Triage!!Isolation !!Mild – moderate inpatient!!Severe case wards!!Critical case wards
|-
| Power – 16A 230V Single socket outlet||As needed ||1 per bed||1 per bed||3 per bed||6 per bed
|-
| UPS Power – 16A 230V Single socket outlet ||As needed||1 per bed||1 per bed||1 per bed||2 per bed
|-
| Medical Air<ref group="Note">Mobile units recommended for intermittent use. 3 per 20 beds</ref><ref group="Note">There are some ventilators which have built-in compressors allowing them to function without Medical Air. This is however, not the norm. With Ventilators probably being the most difficult medical device to obtain at present, it would be prudent to rather allow for Medical Air at each bed.</ref> (LP)400kPa||No||Yes||No||Yes||Yes
|-
| Medical O2 -400kPa||Portable/shared||Portable/shared||No||One||Two
|-
| Vacuum-40kPa||No||Portable/shared||Portable/shared||Yes||Yes
|-
| Equipment rail||||||||Yes||Yes
|-
| Upper room UVGI||Optional||Optional||||||Optional
|-
| Examination light||No||No||Yes||Yes||Yes
|-
| Room Ventilation rate||60 L/s per person||10 L/s per person||10 L/s per person||10 L/s per person||12 ACH
|}
'''Notes: '''
<references group="Note" />

Two additional 16A 230V single socket outlets, one two-pin outlet and a worktop should be provided for every 32 beds (or part thereof), for:
*Electrocardiograph (ECG): Could be omitted if monitors have a full 12 lead ECG function.
*Blood gas analyser: Could be omitted if a Lab Services are available.
*Staff cellphone charging.

Example of healthcare technology to be provided for critical care patients is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]. Severe patients may be provided continuous positive airway pressure (CPAP). Emergency trolleys (“crash carts”) are to be provided in patient areas with convenient access to patient beds, out of the passage of corridors and is moved to the patient when needed. 1 crash cart for every 16 patients (or part thereof, with at least one dedicated for PUIs. An example of provisions for a crash cart is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]
==== Patient ablutions ====
[[SARS-CoV-2 is found in faecal matter]], so careful management of patient body fluids is crucial and convenient, practical support for frequent cleaning of ablutions especially shared ablutions is necessary. Dedicated ablutions (toilets and showers) are to be provided for patient use. Toilets and showers should be in separate rooms.
Hand washbasins and or/ hand sanitiser should be provided both inside and outside the toilet room so that patients can wash their hands on the way in and on the way out of the room.
*1 toilet for every 8 persons.
*1 shower for every 8 persons.
*1 disabled ablution for every 8 regular ablutions (or part thereof).
*1 disabled shower for every 8 persons (or part thereof).

Critical and severe patients may be sedated and have a reduced need to access ablutions, ablution facilities proximity and provision can take this factor into account. Showers and wash hand basins should have hot and cold running water. Where possible ablution facilities must have openable windows for natural ventilation, if not possible the bathroom extraction and room ventilation system must be reviewed before admitting patient '''(see [[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|ventilation]]).'''

Portable toilets and showers may be used, provided that suitable hand wash facilities are provided. These will need to be suitably located, preferably in decentralised clusters, so that patients can easily access them without needing to walk very far. Ablutions should be located and designed in such a way as to provide visual and acoustic privacy, dignity and avoid disturbance of other nearby patients when accessing, using or cleaning the ablutions. Separate ablutions are to be provided for PUIs and confirmed patients.

====Makeshift sluice areas ====
In conventional hospital settings, sluice rooms are provided for cleaning and sanitation of soiled equipment, such as bedpans. In a temporary setting, such as an ACS, the establishment of a temporary sluice room may not be practicable, and there may not be facilities for emptying buckets, rinsing equipment etc.. The following is suggested:
Allocate a toilet, hand wash basin, not in splash range and restrict access to it for draining buckets and install a macerator for disposal of disposable bedpans. Electrical, water and waste supply points required as per supplier specification.
==== Dedicated patient treatment areas ====
The following dedicated, private spaces per ward for clinical procedures are recommended:
*Counselling and consulting room (can be shared), as shown in the figure below
[[File:Consulting room example layout.png|400px|thumb|center|Consulting room example layout]]
*Minor procedures room, as per the example provided in the figure below 
[[File:Treatment-minor procedures room example layout.png|400px|thumb|center|Treatment / minor procedures room example layout]]

== '''Logistical Services''' ==
=== Communications ===
Electronic communication should be facilitated in all zones of the ACS by the provision of device charging stations, and wifi.
=== Visitors entry point ===
Visitors are strongly discouraged from entering the ACS.
*In paediatric wards, one parent may be accommodated to visit a patient. In such cases, direct access for the visitor should be provided so that the visitor does not need to pass through the general patient area. Appropriate PPE must be donned before entering the patient area and hand washing/sanitising must be done when exiting the area.
*Non-patients who are accompanying suspected patients to the facility for testing or admission must be accommodated in a well-ventilated, spacious waiting area. Signage in such waiting areas must inform visitors about symptoms, hand hygiene and PPE.
*Hand washing/sanitizing facilities should be provided.

=== Staff areas ===
==== Staff change rooms ====
A minimum of 9m² or 4m² for a single person, increasing by one m² for each additional person is required. The clean (street side) and dirty (contaminated facility side) of the change room should be separated by a step-over barrier.

==== Staff rest areas ====
Staff rest areas within the main facility should be provided with access to kitchenette facilities and staff ablutions.
=== '''Staff auxiliary services''' ===
'''Staff on-call:'''Since staff may be required to work long hours or could be required to be on-call, shared, overnight sleeping facilities can be provided for staff on duty, outside the contaminated area, but in close proximity on the patient areas. An example is set out in the diagram below.
[[File:Example of on-call sleeping area for staff.png|center|600px|thumb|Example of overnight sleeping area for staff]]

'''Staff accommodation:''' It is advisable to provide some staff accommodation for off-duty staff who may not have suitable alternatives, for example homes too far away, transport limitations or the requirement not to expose family members to risk. This should be provided in the vicinity of the ACS, but in a physically separated zone. This amenity can be outsourced.

== '''Support Services''' ==
=== Workflow principle ===
[[File:Linen processing cycle.png|none|thumb|Linen processing cycle <ref>IUSS 2014 [https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department]</ref>]]
Progressive workflow from “dirty” (that is contaminated) to “clean” linen is advisable to reduce the risk of exposure to contaminated materials. The workflow diagram below, showing the progression from the dirty linen receiving area, to the cleaning process, to decontamination and drying, and finally sorting and packing, and storage, illustrates this principle.
=== Laboratory ===
[[File:Example of modular laboratory.png|right|thumb|Example of modular laboratory]]
The WHO recommends the following laboratory diagnostic equipment be accommodated:<ref>WHO 2020, [https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items]</ref>.
<nowiki>• Lab screening test kit
• Lab confirmation test kit
• RT-PCR kit
• Extraction kit
• Cartridges for RT-PCR automatic systems
• Swab and Viral transport medium
</nowiki>
Additional accommodation requirements are:
# Reception counter- receiving specimens
# Testing with perspex/ glass screen
# Receiving/Data capture
# Specimen holding
# Toilet - staff
# Blood storage fridge
Can be provided as a modular laboratory unit as shown in the diagram.
=== Pharmacy ===
The purpose of the pharmacy is to provide medicines needed for inpatient treatment and care.
All medical supplies should be stored in a secure, climate-controlled area in close proximity to the patient treatment area. The pharmacy must have dry, lockable, climate-controlled storage of medications. Most pharmaceuticals are labelled with storage temperatures. The pharmacy should have adequate ventilation through an openable window to prevent humidity from building up in the room. Air-conditioning or mechanical ventilation can be provided, if necessary.

Dispensing areas must be well lit. Worktop in space for stock records and administration. Dispensing counters to have perspex or glass screens to serveries. Social distancing implemented at counter, between pharmacists/assistants and between chairs in waiting area.

Can be provided in a mobile unit.

=== Radiology ===
The purpose of radiology services is to provide chest X-Ray services for COVID-19 diagnostics. In general, CT scans, bucky rooms etc. associated with some radiology equipment require specialised infrastructure and therefore is not suitable for ACS. Radiology services can be provided as a mobile floor standing unit, or containerised unit. Alternative technologies such as Lodox and hand-held ultrasound devices are being investigated as potential options and could be confirmed as suitable for use in due course.
=== Laundry services ===
All dirty linen should be handled for bagging or binning inside the patient room/cohort area. The clean linen stock should be stored conveniently close to clinical areas, in a dedicated clean area in the uncontaminated zone. Used linen should be stored in a designated, safe, lockable holding area while awaiting collection. Interim storage areas for soiled linen at the wards is allowable; this may be in dirty linen/ utility room.
Any clean linen for PUI areas should be handled in spaces physically separate from dirty linen of confirmed patient areas. It may be necessary to completely separate PUI and confirmed patient linen streams. Soiled linen and clean linen bags and bins should be dedicated and not mixed.
Full laundry cleaning and drying services may be provided on-site or outsourced. If laundry cleaning and drying services were already rendered on or for the host site before it is repurposed as an ACS, then a suitability and risk assessment should be conducted to ensure that the volumes of laundry generated and infection prevention and control measures are conducive and modifications made as necessary. A new full laundry service may take time and resources to establish, and in general, will not be established at a host site as a temporary solution. Where the site and circumstances advocate for the design of a new laundry or the upgrade of an existing laundry, the IUSS Laundry Services for Hospitals should be applied.
==== Siting and model selection considerations ====
When an existing laundry is being assessed for use or a new one is being planned the following considerations apply:
* Water and power capacity.
* Ease of access to the ACS’s main corridors and internal transport routes.
* The noise factor of the facility and its impact on nearby patient care departments.
For outsourced departments:
* Delivery areas to allow sufficient space to ensure that vehicles can manoeuvre and park easily at the reception and dispatch bays.
* Access to the ACS service roads and public roads.
==== Functional requirements ====
The most basic equipment needed in a laundry includes washing machines, tumble dryers and ironing machines. Equipment requiring steam is not recommended for a temporary facility. The sizing of the laundry, equipment and engineering services can be modified based on the principles provided in the IUSS Laundry and linen.
=== Catering services ===
Kitchenettes, that is, areas for tea, coffee and snacks, mainly for staff, in staff pause areas are discussed elsewhere in this document.
Catering services (for staff and patients) may be provided on- or off-site. If the ACS is to be established with easy access to a suitable, existing, functional kitchen service (e.g. hotel, military or hospital catering) which can meet the additional demand of the ACS, then this should be used. If there is no suitable facility, catering should be outsourced via a suitable off-site supplier. Only in the event that no feasible or suitable, existing facility or local supplier is available, should a new catering service be established at the ACS. Detailed guidance for the sizing, design and layout of catering services can be found in the IUSS Catering Services for Hospitals.
The kitchen (for on-site catering) or preparation area (for off-site catering) should be located with easy access to the point of delivery and storage of food. Adequate food and equipment storage space must be provided.
It is recommended that patient and staff meals, where provided, be supplied in disposable, containers, suitable for incineration, and that these are disposed of as risk waste immediately after use.
Where off-site catering is used, a suitable area for receiving should be provided. Space will be required for sorting meals for distribution and collecting and storing dirty dishes, washing dirty dishes, if necessary, and disposing of left-over food and disposable containers and utensils. The size of the areas required for this will depend on the number of meals delivered.

=== CSSD ===
The primary function of a Central Sterile Supply Department (CSSD) is to provide an efficient, economic, continuous and quality supply of disinfected and sterilised items, when needed, to all patient-care service points in the ACS, and to receive returned contaminated items for cleaning.
CSSD with limited sterilisation capacity (autoclave) but sufficient disinfection capacity (instrument washing). The layout requires a designated clean and dirty areas with a hard barrier between to avoid cross-over of staff and equipment. Work is unidirectional - flows from dirty – to clean - to sterile areas.
This yields three distinct zones:
1. Receiving and cleaning with pass-through windows
# Dirty receiving with Perspex or glass partitioning
# Dirty utility
# Decontamination and cleaning/wash area with throughput instrument washing
# Trolley wash/Park – external
2. Inspection, assembly and packaging with pass-through windows
# A tabletop autoclave
# Instrument washer
# Clean Packing area
3. Sterile processing, storage and distribution. (Separate issuing area from receiving area) with pass-through windows
# Store -linen and consumables
# Sterile pack store
# Issue - Collection hatch with Perspex or glass partitioning
Must also have a secure, separate receiving area for consumables receiving and storage.
An example of a CSSD unit is shown in Figure 21.T

[[File:An example of a small CSSD facility.png|600px|thumb|none|An example of a small CSSD facility<ref>IUSS 2014, https://www.iussonline.co.za/norms-standards/support-services/24-central-sterile-service-department</ref>]]

To be understood: Quality of services, eg. water (including a source of distilled or ionised water for rinsing of bronchoscopes) and electricity, quality of management, if equipment is appropriate for needs and fit for purpose, what is required of the equipment in the near and far future (relocation?), compliance with S.A. National Standards for CSSD, compatibility of equipment and devices, correct chemicals, maintenance of equipment, training of operators. Although the use of disposable breathing circuits and accessories (masks) should be encouraged, the capacity to disinfect these items if disposable is not available must be considered.

The CSSD must be sized to serve the ACS. Considerations are workload and space requirements. CFSA has extensive [https://www.fidssa.co.za/Content/Images/CFSA_SOP_2018.pdf standard operating procedures] for CSSD.

Workload: Number and type of procedures, number of procedure rooms, eg for bronchoscopy, operating hours, available inventory, volume of work and peak times, degree of mechanization, eg. manual or automated instrument washing, amount of product to be stored – chemicals, barrier wrap, chemical indicators, etc., storage and distribution records, quality records – eg. equipment checks, disposal needs.

Space requirements: Space for separation of clean and dirty, allow for unidirectional movement, allow space to manoeuvre trolleys (queue, pack/unload), reduce lifting and carrying heavy items, reduce awkward movements, allow for tidy work areas. Insufficient space will compromise sterility!

Preference should be given to construction materials and finishes which are suitable for frequent cleaning and tolerant to chemicals, including bleach (sodium hypochlorite). Impermeable flooring, non-slip and smooth washable walls are needed. Joints at walls and floors and coving at wall edge, and exposed drains should be avoided. Worktops should be sealed and should be ergonomically suitable.

Ceiling heights below 2.8m may be vulnerable to damage from humidity Where steam and moisture are generated. Noise – insulation of washer-disinfector and steriliser in technical walls will reduce noise. Lighting: Natural light if possible – windows sealed. High luminance if artificial lighting. Open, slatted shelves for sterile store area. Sinks for manual washing: At least two basins, deep (25cm at least) basins, 91 cm from floor, wide and long enough for the biggest instrument tray or container, water ports for flushing of lumens.

The CSSD space allocation and layout should be determine based on what procedures and which medical devices will be required. A typical [[equipment list is provided here]].

=== Maintenance and cleaning ===
Maintenance and cleaning services must be accommodated with offices located away from clinical areas.

=== Mortuary services ===
The National Department of Health has issued guidance on handling of dead bodies and infectious remains<ref>National Department of Health South Africa, 2020 [https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf]</ref>, which should be applied to ACS. While some guidelines have recommend that bodies of persons who have died from COVID-19 should only be held for a very brief period prior to cremation or treatment for burial<ref>Zhejiang University, 2020 [http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm]</ref>, the WHO holds the view (at the time of writing) that there is no evidence of persons becoming infected from exposure to bodies during normal ceremonial and burial activities. However, appropriate PPE should be used when handling such bodies with additional airborne precautions to be taken during autopsies<ref>WHO, 24 March 2020 [https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf]</ref>.

Either body cabinets or a refrigerated room could be used for body storage.
==== Location and layout of mortuary service ====
It is likely that not all alternative care sites will have a mortuary. Those without a mortuary must have a holding room that is located away from general access areas. This holding room must be suitably sized and conditioned. A recommended room size is 3.5 m x 3.4 m<ref>IUSS Adult Inpatient Services, 2014, [https://www.iussonline.co.za/docman/document/clinical-services/65-adult-inpatent-services-gazetted/file]</ref>
A mortuary should be located so that it is easily accessible to mortuary staff and related service providers and visitors without presenting either aesthetic, emotional or ethical problems for unrelated staff, patients or visitors. It should be separate from the general facility, allowing access for the family to view a body without passing through any potentially contaminated area of the facility. The visitors’ entrance should be external and completely separate from other access points.
Appropriate routes should be designated so that bodies are not moved through public-access areas.
==== Sizing of mortuary ====
The layout and size of a mortuary are largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.
==== Services ====
The following services are required in a mortuary:
* Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.
* Sluicing facilities are to be provided in both the body-preparation and autopsy areas if they are not a common area.
* Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush-fitted stainless steel grids.
* No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.
* The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.
* Anti-backflow devices should be fitted to the water-supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.
* Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.
==== Finishes ====
Wall and floor finishes should be impervious to liquids and easily cleanable.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Environmental Controls''' ==

== '''General Indoor Environment Conditions''' ==

Existing environmental control systems should be modified to suit requirements in the facility. The following issues should be considered:
* Systems should be set to maximise the introduction of fresh air and maintain the pressure regime (see ventilation).
* The following internal temperature range should be maintained 19 - 24oC.
* Cooling systems should be able to cater for projected internal heat gains from people, lighting and equipment. Indicative heat gains in treatment areas are 8W/m2 from people, 15W/m2 from lighting and 3 W/m2 equipment and in critical care areas 16W/m2 from people, 15W/m2 from lighting and 60W/m2 equipment.
*As heat gain can vary widely between items of equipment, heat gain and utilisation rates for equipment should be obtained from the manufacturer to establish this more accurately.

=== Solid waste from ACS ===
According to the National Department of Health COVID-19 Environmental Health Guidelines
“All solid waste from the facility should be regarded as potentially infectious material and therefore appropriate precautions should be taken". The management of healthcare risk waste (HCRW) should follow the correct identification segregation, storage and disposal processes as indicated in SANS 10248-1.

* HCRW is segregated at the point of generation and shall be containerized to minimize the risk of contamination.
* Waste generated from patients in isolation or quarantine in a designated facility health facility is treated as health care risk waste (HCRW) as per SANS 10248-1-2008.
* The HCRW is properly packaged in a sealed, leak and puncture-proof containers/ boxes.
* The HCRW is labelled with the biohazard symbol/ sign and marked “Corona virus or COVID-19”.
* The HCRW is stored separately from other waste generated.
* The collection, transportation, treatment and disposal is provided by only an appointed/ appropriate contractor/ service provider, however, ensure that waste is safely stored until the health care waste management company can pick it up and that the company knows and acknowledges that waste was generated by suspected or confirmed COVID-19.
* The waste management company collecting must ensure that and treated and disposal is conducted at license waste treatment/ disposal facilities .
* All personnel or staff in contact with patients must be geared with appreciate personal protective equipment (PPE’s) at all times to prevent exposure or risk to health.
* Monitoring should be done at such facilities.
* All, bags, bins and boxes must be adequately sealed, as not to leak any fluids, and must be wiped down with 0.05% chlorine solution

Measures developed should consider the following.
* Develop a waste management plan following national guidelines and best practice standards for the disposal of medical waste (WHO, 2020).
* Establish procedures with medical waste service providers to regularly pick up the waste and dispose of this safely.
* Provision should be made for 5kg of solid waste per bed per day and this should be monitored and supplemented where it appears this may be inadequate.
* Ensure that access to waste is secure and controlled, for instance, by using lockable waste 1000l containers kept in a location that can only be accessed by health facility and nominated service delivery staff.
* Vermin control programs must be implemented throughout the site with HCRW collection points prioritised
* Provision for safe cleaning and disinfection of reusable containers should be provided. Cardboard, single-use HCRW boxes are removed from site and incinerated.
* Waste must not be allowed to accumulate or be stored inappropriate or unsecured containers.

== '''Engineering Services''' ==
Engineering services include patient services, ventilation, electrical power, water, medical gases, oxygen, compressed air, vacuum, lighting, and fire safety that support the needs of the patients and medical staff under normal and emergency situations. Good practice standards are provided in:
* IUSS Building Engineering Services<ref name = "IUSSBES">IUSS 2017, [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file]</ref>
* NHS Nightingale Instruction Manual<ref name="BDP2020">BDP 2020, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf]</ref>.
The guidance below draws on these and other manuals and standards. 

=== Building ventilation ===
==== Mechanical ventilation ====
While SARS-CoV-2 RNA has been detected in aerosol form, in experimental mechanical aerosolization studies, it is primarily spread through droplet and contact spread and the potential for airborne transmission is thought to be low.
However, the following advice is provided by ASHRAE regarding HVAC systems in general spaces (not specific to healthcare):
Effective high levels of ventilation must be achieved in the facility. Existing ventilation systems should be tailored to suit internal layouts and requirements and the following measures should be taken.
* Mechanical systems should be set to maximise fresh air supply to the facility. There should be no recirculated air without HEPA filtration or other validated decontamination processes.
* A pressure regime should be established, as shown in figure 2, to 'push' air from clean areas, to dirty areas and then out of the building.
* A clean air supply of over 10 L/s per person should be targeted for odour control.
* Fresh air supply shall not be located near patient beds to avoid drafts in winter.
* Extraction points can be located near patient beds in isolation wards or at a high level in long-stay wards. Short-circuiting of air between high-level supply and extraction is a performance risk in winter.
* Noise from ventilation systems and fans shall be below 45 dBA
* Protected lobbies, internal partitions, door arrangements, fans and extracts should be used to maintain the pressure regime and airflow as indicated in the diagram below.
 

[[File:Ventilation in temporary facilities.png|600px|thumb|none|Ventilation in temporary facilities<ref name="BDP2020"/>]]

==== Natural ventilation ====
The airflow direction between naturally ventilated zones may fluctuate according to the wind direction. This is not of concern within and between contaminated zones where occupants are either protected with mandatory PPE or confirmed to be infected with disease strains similar enough so as not be able to reinfect others. Where levels of occupant susceptibility to an airborne disease is significantly different, the less susceptible areas (such as PUI areas and uncontaminated areas) shall be protected from the naturally ventilated and contaminated areas by mechanical ventilation systems with a capacity sufficient to overcome the expected natural ventilation pressure fluctuations (typically 5-15Pa). Where such mechanical ventilation systems are not feasible or expected wind pressure is too great, zone adjacently must be avoided.

===Ultraviolet germicidal Irradiation===
The application of Ultraviolet Germicidal Irradiation (UVGI) for room air disinfection is well understood and is proven to be effective in the disinfection of microorganisms including M. tuberculosis (TB) in air. UVGI should, therefore, be considered as a valid element in indoor airborne infection control strategy for high volume settings. Studies have demonstrated the importance of good vertical air mixing in the room, and the safety of UVGI application. In areas where UVGI is indicated, the design and development of UVGI systems should be in accordance with the [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]<ref>van Reenen et al,2019 [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]</ref>

=== Electrical power ===
Sufficient and reliable power must be available at the facility for envisaged medical equipment, medical gases, lighting and building ventilation equipment. Power installations for the temporary facility can be divided into three zones as indicated below. These are existing services, the temporary service zone and services in each bay.
The following should be considered by competent engineering professionals.

=== Existing services ===
*Capacity: Evaluate whether sufficient power to accommodate envisaged medical equipment, additional lighting and heating, building ventilation and air conditioning can be provided. If existing capacity is insufficient, investigate if it is possible to route additional power from additional locations/transformers around the site or from adjacent sites.
* Safety: The existing electrical distribution network must be able to supply the required equipment load. If this is insufficient/appears unreliable, identify how this can be supported.
* Resilience: Evaluate back-up power and a UPS capacity against essential services demand. If existing capacity is not sufficient, source and establish temporary service capacity.

=== Temporary service zones ===
*Identify locations for temporary service zones where equipment can be located.
*Ensure that equipment and maintenance access is safe and easy.
*Ensure that all distribution boards, circuit breakers and cables are clearly labelled.
=== Services in each bay ===
*Provide pre-wired power strips/trunking as per bay requirements.
*Check that these include sufficient electrical outlets and service points for envisaged equipment.
*Ensure that trunking will carry required equipment loadings. The IUSS Building Engineering Services Guide can be used to check requirements<ref name = "IUSSBES"/>.

[[File:Layout_of_power_in_a_temporary_installation.png|600px|thumb|none|Layout of power in a temporary installation <ref name="BDP2020"/>]]
----

=== Water ===
Water points are needed for handwashing, showers and cleaning. The following issues need to be taken into account.
==== Supply ====
Onsite cold water storage, dedicated to the domestic water requirements of the facility, should be provided. A minimum usable volume of 500 litres per bed should be available.
Hot water storage and consumption should be confirmed by an engineer, as follows:
*Storage 25 L per bed.
*Consumption 180 L/bed.day W/O laundry; 250L /bed. day W laundry.

==== Handwashing ====
See infection control for clinical wash-hand basins
==== Showers ====
Showers for staff coming off shift should be available. Staff flow routes exiting contaminated treatment areas should pass through gowning and shower areas.
----

=== Medical gases, oxygen and vacuum (suction) ===
Medical gases, oxygen and vacuum services will be required in the facility. Mobile gas supply requires piping between supply and patient and clutter floor space. Preferably used fixed installations for patient rooms/cubicles, if possible.

System capacity and point of use pressures and consumption rates are to be ensured at all points. WHO provides technical guidance on [https://www.who.int/publications-detail/oxygen-sources-and-distribution-for-covid-19-treatment-centres oxygen sources and distribution]. 
[[File:Medical gas service layout.png|6oopx|thumb|Medical gas service layout<ref name="BDP2020"/>]]
The following points should also be taken into account.
* For centrally supplied medical gas and vacuum services, system resilience and availability must be ensured.
* Compressors, tanks, accumulators, VIEs, headers and controllers must be secured from uncontrolled access.
* Where possible, gas piping should be reticulated below floors or in ceilings to ensure protection from tampering, damage and ease of access.
* Where reticulation is within open areas, high-level reticulation with point-of-use droppers is advised. Low-level reticulation within rooms is to be avoided.
* Flexible piping can be used, ensuring it does not present a contamination or fire risk and should comply with local regulations. Special care should be taken with flexible O2 piping, keeping it to a minimum.
* Vacuum piping may be contaminated, where point-of-use filtration and collection systems fail. Precautions should be taken when demounting or disconnecting temporary vacuum lines.
* Ensure that oxygen pipelines are designed to provide sufficient flow to all oxygen points in the facility. In terms of utilities, oxygen and medical air would be required. A temporary vacuum point can be provided by mobile medical vacuum units distributed throughout the unit.
* Mobile medical air supplies should be considered where reaching piped specifications are not feasible. Where flexible hoses are used for oxygen and medical air special precautions need to be taken. Flexible oxygen piping must be chemically safe for O2 use. Where perishable flexible piping is used for medical air, terminal filtration at the point-of-use may be required at point-of-use. Especially for long-term use.
* Electrical and gas services can be reticulated against pipe racks or boards fixed to the bed-heads for head to head bed arrangements.
* Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.
* Gas service outlets to be labelled and colour-coded with 3mm lettering.
* SANS 7396-1 should be used to specify the requirements from design to commissioning of medical gas and vacuum systems.
* Medical gas and vacuum pipelines shall be marked per SANS 7396-1 and ISO 5359, as applicable.
* Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.
* SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.
* Plain-ended copper tubing for low-pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.
* Laboratory gas taps and valves shall be marked as described in SANS 10140-4.

=== Lighting ===
Existing lighting systems may need to be modified to suit the clinical requirements in the facility. High bay lighting presents inadequate colour rendering quality for the accurate detection or easy diagnosis of certain clinical conditions. This needs to be evaluated in the selection of supplementary lighting systems.
*Lighting levels should be provided in line with the indoor lighting levels recommended in the Table 6 of IUSS Building Engineering Services .
*Mobile task lighting systems may be adopted in the serious and critical stay wards to supplement incorrect lighting quality.
*Emergency lighting and illuminated emergency egress signage should be linked to the back-up power system.
*External security lighting in external parking areas and spaces around the building should be enhanced to ensure the security of medical staff who need to change shifts at night.

=== Fire safety ===
A functional fire alarm system should be available to support the patient care setting. Fire is a very real threat due to the possibility of an oxygen-enriched atmosphere developing so ventilation is crucial.
The use of temporary facilities for medical care should note the following fire risks (NHS, 2020):
*Patients may have a very high dependency.
*Areas are not specifically designed for patients and do not meet guidance on fire compartmentation and progressive horizontal evacuation.
*Large numbers of patients supplied with oxygen up to 10 litres per minute.
*Possibility of oxygen concentrations exceeding those generally found in the atmosphere- less risk if effective ventilation or large volume i.e. high ceilings.
* Possibility of storage, in excess of 40 litres, of alcohol-based chemicals (such as hand-rub), necessitating a flammables cabinet on site.
*Staff who may not normally work together .
*Staff who may not be familiar with the area.
*Staff not trained in fire safety, progressive horizontal evacuation or oxygen isolation for the specific area.
These factors should be taken into account in fire risk assessments which should then address significant findings in an action plan. Fire assessments should be undertaken by a qualified person and shared with operations and building management staff within the facility. Measures developed should include:
*An automatic fire detection system
*An emergency egress plans are prepared that include patients who have a very high dependency.
*Signage, notices and lighting are installed and are working effectively.
*Management processes are in place to minimise the risk of fire from ignition sources, fuels and oxygen.
*Staff are trained and a fire safety guide sheet for staff is developed and issued.
*Emergency egress routes are kept clear.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Additional Resources''' ==
=== [[Directory of Service Providers|A Directory of Service Providers can be viewed here]] ===

=='''References'''==
<references />

[[Category:COVID-19| ]]
[[Category:Alternate Care Sites|Alternate Care Sites]]

----
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19|(Return to Top)]] 
----

Infrastructure Guidance for COVID-19/Alternate Care Sites

2020-05-08T08:41:37Z

Peta: /* Establishing a team */

[[Infrastructure Guidance for COVID-19|Return to Infrastructure Guidance for COVID-19]] 

== '''Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19'''==

This guidance work was initiated under the project titled: 
''Reducing Nosocomial and Community-Acquired Tuberculosis by Strengthening the Capacity of the South African Department of Health to Improve Implementation of Infection Control and Waste Management at All Levels of the Health System Under the President's Emergency Plan for AIDS Relief (PEPFAR)'' 

== '''Purpose and Approach''' ==
The global pandemic of COVID-19 caused by the coronavirus, SARS-CoV-2 is likely to result in a surge in need for medical care for Severe Acute Respiratory Syndrome (SARS) in South Africa. Considering the course of the pandemic in other countries, it is anticipated that South African hospitals will not have sufficient capacity to cope with the surge of persons requiring medical attention and that surge capacity via alternate care sites (ACS) will need to be established.
Surge capacity, contemplated here is not the frequent emergency department overcrowding experienced by healthcare facilities (e.g. Friday/Saturday night emergencies) or local casualty emergency that might overcrowd nearby facilities and have little to no impact on the overall healthcare delivery system. It is when a catastrophic event occurs and the affected population seek medical care from existing local healthcare facilities, causing healthcare infrastructure to become exhausted due to excess in demand. During a healthcare surge, the standard of care will shift from focusing on patient-based outcomes to population-based outcomes, and providers should anticipate “a shift to providing care and allocating scarce equipment, supplies and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals.”<ref>[https://asprtracie.hhs.gov/technical-resources/resource/491/altered-standards-of-care-in-mass-casualty-events Health Systems Research Inc., 2005]</ref> 

Surge capacity can be temporarily established in non-traditional environments, such as hotels, exhibition halls, community halls, and as field hospitals, on open spaces. 

In the context of this document, a quarantine site is a facility for patients who do not require continuous professional medical care, while an ACS is defined as a temporary facility that can provide continuous medical care for SARS. This document provides principles and considerations, high-level guidance for minimum requirements and examples for ACS. 

While an extensive set of health facility guidelines does exist<ref>[https://www.iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-servi IUSS Building Engineering Services (2017)]</ref>, these are applicable for conventional facilities and thus include services and guidelines that are not necessarily relevant to the treatment of a novel, highly infectious pathogen, with pandemic effects. Moreover, these do not provide well for the rapid and temporary establishment of facilities. 

In order to formulate high-level guidance, [[as invited by Business for South Africa]], the team reached out to professional industry bodies for inputs, in particular the South African Institute for Architects (SAIA), The Gauteng Institute for Architects (GiFA) [https://www.gifa.org.za/ Gauteng Institute for Architecture] and the [http://www.safhe.co.za/ South African Federation of Hospital Engineering (SAFHE)], by inviting input via a 36-hour research charrette. Relevant historical and contemporary literature was consulted, precedents identified and critically reviewed. An interaction with the team at Wuhan responsible for makeshift hospitals and emergency infectious diseases hospitals, Central-South Architectural Design Institute, was arranged with assistance of the Chinese Embassy. Material from the [[Infrastructure Unit System Support|Infrastructure Unit System Support (IUSS)]], international literature and guidance and input gathered from the broader architectural, engineering and healthcare professional communities was synthesised and moderated by the CSIR team. The draft was reviewed by an expert review panel. 
=== Acknowledgement of contribution ===
The contributions to the initial version of this were gratefully received. [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Acknowledgements|A list of these contributors can be viewed here.]]. 
New contributions are eagerly encouraged along with debate and discussion on the [[Talk:Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites|'''discussion forum.''']] tab above.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Scope and Assumptions''' ==
ACSs as discussed in this document are dedicated, temporary facilities for triage, testing, diagnosis, further referral and treatment of persons:
*suspected of having contracted SARS-CoV-2, (persons under investigation (PUIs)), who are symptomatic and/or are awaiting results,
*or are confirmed to be infected.
ACS will accommodate a variety of clinical, logistical, support and auxiliary services associated with the render of care. ACS will currently not be licensed to provide healthcare services. Since the ACS will operate in a non-healthcare facility, it cannot fully replace a hospital setting and its prime objective is to manage the patient load until the local healthcare system can meet demands. 

=== Exclusions ===
Quarantine facilities are accommodation facilities where a member of the community can remain for the duration of their isolation period. This is typically temporary housing for a cohort of people who do not need intensive medical attention but who cannot stay at home. Patients can take care of themselves and need limited monitoring by medical staff. Quarantine: Containing presumptive-case patients from each other and the general population.
Quarantine facilities – that is for asymptomatic persons who are in the community in self- or imposed isolation, but not displaying symptoms, or who are symptomatic, but are able to safely recover without clinical intervention and do not need continuous medical observation are not considered in this document.

=== Service regime ===
The following assumptions are made with respect to services under consideration.
* Temporary - limited to the part of the pandemic when the “conventional” hospital platform cannot meet demand. To be dismantled, thereafter.
* Uncomplicated, dedicated COVID-19 care is to be prioritised for ACS.
* Patients with comorbidities, paediatrics will be prioritised for conventional facilities, and only accommodated in ACS as a matter of last resort.
* 24 hour, 7 days a week operations. 

=== Assumed mechanism of transmission ===
Transmission of SARS-CoV-2 is understood to be from person to person firstly by [https://en.wikipedia.org/wiki/Transmission_(medicine)#Droplet_infection droplet] transmission, then by the [https://en.wikipedia.org/wiki/Transmission_(medicine)#Direct_contact contact] route and finally via airborne [https://en.wikipedia.org/wiki/Transmission_(medicine)#Airborne_airborne transmission] during or following mechanical aerosolisation. Water transmission risks are minor, occurring in special [https://en.wikipedia.org/wiki/Transmission_(medicine)#Fecal%E2%80%93oral Fecal-oral] circumstances. Reclassification of transmission mechanisms may nullify some of the approaches presented in this guidance. 

=== A call for strategic coordination ===
This document focusses on infrastructure requirements. These provisions are meaningless without staffing, equipping and resourcing. Whilst staffing, equipping and resourcing are not the focus of this document, these are likely to emerge as key constraining features. Resource constraints are likely to become acute during this pandemic. Doctors and nurses are already in critical short supply in South Africa and internationally, and are themselves susceptible to COVID-19 infection. Equipment and consumables are in short supply with heightened global demand, reduced manufacturing capacity and limits in trade flows. This necessitates strategic coordination, proactive planning, options appraisal and prioritisation. 

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Status Quo''' ==
=== Rationale and transmission status ===
According to the [https://en.wikipedia.org/wiki/World_Health_Organization World Health Organisation] (WHO), based on the largest cohort of COVID-19 patients, about 40% of patients with COVID-19 may have mild disease, where treatment is mostly symptomatic and does not require inpatient care. About 40% of patients have moderate disease that may require inpatient care; 15% of patients will have severe disease that requires oxygen therapy or other inpatient interventions, and about 5% have critical disease that requires the patient to receive mechanical ventilation. However, the evolution of the outbreak in some countries has shown a higher proportion of severe and critical cases and the need to rapidly increase surge capacity to prevent rapid exhaustion of biomedical supplies and staff. In some countries, doubling rates of cases every three days has been observed<ref>WHO-2019-nCoV-HCF_operations-2020, [https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf]</ref> 

South Africa has a high burden of disease, with a high prevalence of [https://en.wikipedia.org/wiki/HIV/AIDS_in_South_Africa HIV and TB]. Although evidence is yet to emerge of the effect of SARS-CoV-2 on a population with these pre-existing conditions, there is reason to proceed with caution<ref>The Conversation 2020, https://theconversation.com/tb-hiv-and-COVID-19-urgent-questions-as-three-epidemics-collide-134554</ref>. There is a potential direct and indirect benefit of ACS to people living with HIV and TB, as well as to general public health and the health system preservation. 

With the travel lockdown in place, and continued transmission, it appears that South Africa is on the cusp between cluster transmission and community transmission according to WHO’s classification, shown in the [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites#Key_clinical_and_infection_control_activities_for_different_transmission_scenarios_.5B3.5D|table below]], indicating that preparation should include temporary hospital facilities and mass critical care.

==== Key clinical and infection control activities for different transmission scenarios <ref>WHO 2020, [https://apps.who.int/iris/handle/10665/331492 https://apps.who.int/iris/handle/10665/331492]</ref> ====
{| class="wikitable"
|-
! !! '''No Case''' !! '''Sporadic Case''' !! '''Clusters of Cases''' !! '''Community Transmission'''
|-
| Faculty Space, Including for Transmission|| Usual Space. Enhanced Screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards). || More patient care areas re-purposed for COVID-19 within the health system, especially for severe cases || Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Staff|| Usual space. Enhanced screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards)||More patient care areas repurposed for COVID-19 within the health system, especially for severe cases||Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Supplies||
*On-hand supplies. Equip wards for COVID-19 treatment.
*Identify essential equipment and supplies, including oxygen.
*Prepare expanded local supply chain
||
*Expanded inventory of supplies with detailed protocols for use.
*Activate expanded local supply chain.
*Prepare national supply chain.
||
*Conservation, adaptation, selected re-use when safe.
*Activate contingency planning and procurement for essential equipment and supplies.
*National supply chain.
*Prepare expanded supply chain at the global level
||
*Activate contingency planning should critical equipment be in short supply.
*Determine allocation of lifesaving resources for HCWs and patients.
*Activate expanded global supply chain
|-
| Standard of Care|| Usual care with enhanced awareness and recognition of immediate needs for first COVID-19 patients|| Usual care and treatment for all patients, including those with COVID-19||Identify context-relevant core services. Shift service delivery platforms. Consider reduction in elective patient encounters, including elective surgical procedures.|| Mass critical care (e.g. open ICU for cohorted patients).
|-
| Care areas expansion|| No requirements for expansion|| Designate 10 beds per suspected COVID-19 case|| Expand COVID-19 patient care areas by a factor of 35 ||Expand COVID-19 patient care areas by a factor of 58
|}

=== Quantification of need ===
At this time there are various parallel initiatives aimed at forecasting the South African epidemic, quantifying the projected need for facilities, and a shortfall in existing capacity. At this time, there is no consensus on this. This section will be updated as further data becomes available.
ACS will prioritise mild to moderately affected COVID-19 patients where basic, targeted medical care will be provided. Should patients’ needs evolve, requiring escalation of care, then the transfer of patients from ACS sites to conventional sites of care will be needed as a matter of course, bringing with it logistical challenges and risks. In the event that the conventional hospital platform is unable to cope, ACS will have pressure to provide care for severe and critical patients, and finally for patients with comorbidity and special requirements, such as paediatrics, persons living with HIV (PLHIV), TB patients and pregnant women. The following pragmatic approach, aligned with the WHO recommended strategic approach, is suggested.
*ACS should preferably be identified with space for expansion.
*The set-up should be done so that levels of care can be upgraded to higher levels of uncomplicated care.
*A secondary upgrade for more diverse package of care may become necessary.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Strategic Approach''' ==
According to WHO, clinical interventions must be put into place immediately and then scaled up according to the epidemiologic profile.
[[File:COVID-19 Resource allocation.png|none|thumb|600px|right|WHO Strategic approach to clinical care]] 
Under this declared state of disaster, the clinical care strategy which cannot be accommodated within existing facilities, can, on a temporary basis be hosted in ACS:
*Within and around existing healthcare facilities, via reconfiguration and/or augmentation.
*In existing non-healthcare buildings suitable for repurposing, such as universities, hotels and conference centres, warehouses, gyms, hostels etc.
*On open fields, including paved parking areas with rapidly constructed, dismountable structures, such as modular tented structures or using rapid modular construction techniques. 

ACS will provide isolation, general (non-acute) care for patients with mild to moderate symptoms and as required, acute care for patients with severe symptoms. Containing confirmed-case patients from general population. Confirmed-case patients can be housed together en masse, while presumptive-case patients must be individually quarantined.
As shown in the WHO Strategic approach to clinical care, the WHO recommends a range of services to meet patient need (''Citation needed''). General (non-acute) care ACS model is designed for minimal acuity patients requiring minimal activities of daily living support (e.g. COVID-positive with minimal symptoms or require <2L of oxygen). Acute care ACS model is designed for higher acuity patients requiring closer monitoring or respiratory support (e.g. COVID-positive with pneumonia or respiratory distress requiring ventilator support). Paediatric patients are to be accommodated in separate wards, where strictly controlled visitation may be allowed. 
As a preliminary estimate, the following ratios of service is proposed:
[[File:COVID Ratios of Service.png|none|thumb|600px|center|COVID Ratios of Service]]

{| class="wikitable"
|-
! '''Case severity, risk factors<ref group="Notes"> Test suspect COVID-19 cases according to diagnostic strategy</ref><ref group="Note"> Known risk factors for severe COVID-19: age over 60 years, hypertension, diabetes, cardiovascular disease, chronic respiratory disease, immunocompromising conditions.</ref>''' !! '''Recommendations'''
|-
|Mild || Patient should be instructed to self-isolate and contact COVID-19 information line for advice on testing
and referral.
|-
|Moderate, with no risk factors ||Test suspected COVID-19 cases according to diagnostic strategy. Isolation/ cohorting in:
* Health facilities, if resources allow;
* Community facilities (e.g. stadiums, gymnasiums, hotels) with access to rapid health advice
(i.e. adjacent COVID-19 designated health post/EMT-type 1, telemedicine)
*Self-isolation at home according to National guidance
|-
| Moderate, with risk factors || Patient should be instructed to self-isolate and call COVID-19 hotline for emergency referral as soon as possible
|-
|Severe || Hospitalization for isolation (or cohorting) and inpatient treatment.
|-
|Critical|| Hospitalization for isolation (or cohorting) and inpatient treatment.
|}

=== Notes and References: ===

<references group = "Note" />
<references />

=== Typology dictates & case studies ===

[[File:NHS Nightingale Hospital London.png|thumb|NHS Nightingale Hospital London <ref name="NHS Nightingale Hospital London">Coronavirus: Building NHS Nightingale Hospital London, 2020 [https://www.bbc.com/news/in-pictures-52092253 https://www.bbc.com/news]</ref>, ]]
To meet the requirements set out in this guidance, prospective “host” sites should be carefully evaluated. The type of “host” site selected will strongly influence or dictate the choice of ACS service model.

No site is likely to meet all requirements and recommendations set out in this document. Adaptations and compromises will be necessary. Services should be provided on site where it is pragmatic to do so, for example where similar services are provided. Outsourcing can also be practical/feasible for some services, such as laboratory services, catering and laundry, provided suitable logistical arrangements can be made.

Some typological responses and service models are set out in precedent examples, shown below. The examples demonstrate that a variety of host settings are workable, provided that the appropriate utility can be contrived.

=== Pragmatic approach ===
Other than in metropolitan areas, co-location of ACS on the premises of, or adjacent to existing healthcare facilities will often be preferable because this is where intensivists and specialist clinical staffing will be available, and support services may be well established. Nevertheless, augmenting capacity at existing facilities should take into account current workloads and capacity to ensure that the COVID-19 surge disrupts normal service provision as little as possible, including continuity of care for patients with chronic conditions and TB and HIV patients. 

*'''[[Infrastructure Guidance for COVID-19/Alternate Care Sites/Case Studies|SARS ACS Precedents and Case Studies can be found here]] '''

=== Notes and References ===
<references />

== '''ACS Infrastructure Planning''' ==

=== Establishing a team ===
A planning team should be formalised to establish the minimum planning and operational requirements for the ACS and to liaise with the local community. The team should include individuals with expertise in the following areas (ideally with knowledge of healthcare delivery under emergency conditions):
*Disaster response / emergency management coordination,
*Clinical care and staffing,
*Infection Prevention and Control practitioners must be involved in all stages of planning, commissioning, in-use, and decommissioning of the facility
*Facility set-up, operations and management,
*Security,
*Transport (patient, staff),
*Engineering and project management,
*Procurement and coordination of supplies, equipment and pharmaceuticals, and
*Community liaison to ensure that concerns of the adjacent population on understood an addressed.
It is important to ensure compliance with health, safety and building regulations, by ensuring the involvement of relevant local authorities. Stakeholder engagement should be formally documented. Concerns and grievances should be systematically addressed.

=== '''Structural integrity and operational responsibility''' ===

'''Structural modifications:''' ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered. 

'''Competent person:''' All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed. 

'''Asset responsibility:''' Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented. 

'''Integrity and responsibility'''

'''Structural modifications''': ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered.

'''Competent person''': All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed.

'''Asset responsibility''': Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented.

'''Decommissioning''': Decommissioning of the facility shall be assigned to the competent person discussed above. All residual structures upon decommissioning shall comply with the National Building Regulations. Upon decommissioning, removal of equipment shall be the responsibility of the owner. An infection prevention and control practitioner should be engaged in the decommissioning phase to oversee terminal cleaning and disinfection of equipment and premises.

'''Closure''': Once all patients can be safely discharged or transported back to existing facilities for continued care and there are no ongoing healthcare surge capacity needs, the ACS can be closed. Shut down of an ACS will require decommissioning, identification of new homes or storage for equipment, and termination of ongoing contracts or arrangements. Shut down should be expedited so that the facility can quickly be returned to the control of the existing owners and returned to its usual function.

Action checklist items for ACS closure should include, but not be limited to, the following:
*conduct a site walk-through with the facility owner when shutdown activities are completed to ensure that terminal cleaning and disinfection of supplies and premises, removal of equipment and supplies, and other surge closure activities have been completed to the owner’s satisfaction.
*perform medical records storage procedures.

== '''Site Selection''' ==
When selecting a site, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital can be utilised to determine whether the site is suitable for a 100, 1000 or 2000 bed facility, as required. The following indicative minimum site sizes are needed:
*100 Bed ACS/ hospital conversion, requires ± 4 300 m2
*1000 Bed ACS/ hospital conversion, requires ± 17 600 m2
Evaluation should be done by examining plans (if available), satellite images, drone images, scans and by physical inspection (walkabout). A comprehensive photographic survey should be undertaken and retained for record purposes on the site inspection. This will serve as an audit record and may assist in returning the site to its original function on ACS decommissioning and closure. When scrutinising documents and conducting site inspections to confirm the suitability of a site to host an ACS, the following criteria should be taken into account.
=== Criteria ===
*Affordability (costs, including operational costs known and budget identified),
*Sufficient physical space and capacity to house the immediate need, with the potential to accommodate physical space requirements. For example, open site should not be sloping,
*Legal rights and encumbrances, including renewal opportunity,
*Good access to highway and main roads,
*Well secured perimeter and limited controlled access points,
*Proximity to other hospitals and care sites,
*Accessibility for key staff and public transport,
*Good vehicular access around the site to set up temporary equipment such as back-up generators,
*Free from clear and present danger,
*Outside attenuation zones, floodplains,
*Outside high wind zones,
*Structure in good repair,
*Effective onsite facilities management team who understand how systems work,
*Potential for expansion, if required,
*Access to sufficient capacity for
**potable water,
**adequate sewage,
**telephone,
**internet access with sufficient bandwidth,
**electricity,
*A zone for cleaning, disinfection, and decontamination of equipment at least 15 metres away from occupied areas with access to water, a hard impervious surface and drying areas in the sun, with runoff discharge into the sewer and not into marine ecosystems or the environment. Include area for cleaning and storage of cleaning equipment.
*Likelihood of acceptance of hosting an ACS by the adjacent and local community

=== Desirable ===
*Durable, cleanable surfaces,
*Large open spaces that can be converted to accommodate temporary structures,
*Good ventilation,
*On-site kitchen and laundry,
*Housekeeping staff (chemical and equipment storage, lockers, rest facility, administration office),
*Space conducive for staff respite area and locker rooms,
*Amenities with universal access,
*Fire protection safety and equipment,
*Elevator access for patients if the building has more than one floor,
*Capacity for expansion, and
*Accessible to at least two roadways to provide continued access in the event that one roadway becomes blocked on inaccessible.

== '''Infection Prevention and Control''' ==
General guidance for COVID-19 [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|Infection Prevention and Control]] can be accessed [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|here]] 

Infection prevention and control in the context of COVID-19 should respond to transmission routes of primary concern for the pathogen of interest (droplet and contact transmission, and management of risk waste) as well as infection risk of a general nature (water and sewerage, airborne transmission – under high TB/HIV burden, and general waste).
In addition to satisfying [https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html standard precautions for all patient care], transmission-based precautions should focus on three pillars: exposure reduction by spatial configuration, operational strategies, and personal protection.
=== Transmission-based precautions ===
'''Droplet and contact spread''': Transmission of SARS-CoV-2 virus occurs via droplet and contact spread. The virus has been shown to persist on surfaces for extended periods of time and is known to be efficient at infecting people. 

'''Medical waste and linen:''' As SARS-CoV-02 is carried in body fluids and faecal matter, disposal of contaminated items (tissues) and cleaning regimes (spaces, garments, linen) should be accommodated carefully in the workflow design and infrastructure provision. A site-specific waste management plan should be formulated in accordance with a site-specific waste management plan with reference to SANS 10248. 

'''Airborne transmission:''' Under exceptional circumstances, the risk of airborne transmission arises for SARS-CoV-2, as detailed below.
{| class="wikitable"
|-
!Airborne Transmission Risk Factors
|-
|
As SARS-CoV-2 is not considered airborne, respiratory protection against airborne transmission is not considered necessary, except where aerosolisation of particles may be a risk.
According to the CDC
*tracheal intubation,
*non-invasive ventilation,
*tracheotomy,
*cardiopulmonary resuscitation, or
*manual ventilation before intubation and bronchoscopy.
According to doctors in the field also when performing
*COVID-19 diagnostic sampling as patients can be induced to cough and sneeze.
*Suspected or confirmed comorbidity of TB is not an additional risk where correct COVID-19 PPE is applied.

|}
South Africa has a high prevalence of TB and HIV, and therefore, although the risk of COVID-19 transmission via the airborne route is not paramount, there is a high likelihood that undiagnosed TB infectious patients may present at the ACS for treatment. TB triage may be challenging in the ACS as there are symptoms in common (coughing) with COVID-19. This country-specific risk is taken into account in this guidance

=== Additional precautions ===
'''Water and sewerage contamination:''' The International Water Association [[Infrastructure Guidance for COVID-19/Alternate Care Sites/COVID-19 A Water Professionals Perspective|concluded]] that water and sewerage contamination is not considered to be a key risk factor for COVID-19. The panel expressed concern for “how waste and specifically wastewater (medical) would be handled by places (e.g., hostels, hotels) that are used to serve as interim COVID-19 quarantine or testing facilities or accommodation ([ACS]. These are places other than hospitals that are used in the interim for such purposes and do not usually handle wastewater from medical settings. Such facilities should be monitored carefully.” 

== '''Spatial strategies for infection prevention and control''' ==

=== Restricted access and zone control ===
The site will be arranged to establish clear zoning, with a clear restricted zone protocol and access protection. Zones should be deemed to be "contaminated" or "uncontaminated" with clear transition areas between them.

; Contaminated zones
: (also known as "dirty areas") are areas occupied by COVID-19 infected persons, PUIs, equipment, materials and supplies which have come into contact with such persons without yet undergoing a decontamination procedure. These areas will include patient ward areas and ablutions, patient admissions (including ambulance drop-off) and the associated clinical areas. Staff rest and dining facilities should be outside the contaminated zone. Limited stock for immediate use should be kept in the contaminated zone. Layout designs should consolidate contaminated zones as far as reasonable, and avoid uncontaminated zones as islands in contaminated zones.

; Uncontaminated zones
: (also known as "clean areas") are areas not generally occupied by PUIs or confirmed COVID-19 infected persons. Equipment, materials and supplies in these areas have not yet come into contact with contaminated zones or have undergone a decontamination procedure. These will include clinical management planning rooms, stock rooms, bulk stores, pharmacy, laboratory areas, kitchen and laundry.

; Transition zones
: (also known as intermediate zone) are the spaces through which transfer of people and goods from uncontaminated to decontaminated zones, and vice versa, occur. Materials from the contaminated zone should be decontaminated or contained in the transition zone. The transfer of goods and persons should be highly ritualised and, as far as possible, traffic across transition zones should be minimised. Transition areas should be strategically located to serve this function. Separation of in-going and out-going transfer of goods and persons is preferable. Transition areas include ambulance, trolley decontamination, CSSD, laundry and waste bagging areas, patient locker area and staff change areas with spaces for donning and doffing of PPE.

=== Site layout and master-planning ===
Spatial configuration and layout can ensure unnecessary cross-over of function is avoided. This entails the systematic separation of functions and the managed transition between activities to facilitate consistency of care, an orderly, efficient work environment, less waste and reduced risk for improved outcomes. To achieve this, functional relationships should first be considered at the site level before being considered at the building level. 

<gallery mode=packed heights=300px style="text-align:left">
Layout for a SARS facility, clustering functions with minimised cross-over.png|center|thumb|Layout for a SARS facility, clustering functions with minimised cross-over <ref name="Layout1">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Layout_for_a_Patient_cohorting_strategy.png|center|thumb|Layout for a Patient cohorting strategy <ref name="Layout3">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Tygerberg Hospital virus triage unit site layout.png|center|thumb|Tygerberg Hospital virus triage unit site layout <ref name="Western Cape Provincial Government, 2020a">Western Cape Provincial Government, 2020 a</ref>
</gallery>

The WHO's Clustering Layout <ref name="Layout1"/> and Tygerberg Hospital virus triage unit<ref name="Western Cape Provincial Government, 2020a"/> show worked examples of building and site layouts, which are configured with these principles, respectively. '''Cohorting''' is defined as clustering patients with similar or compatible clinical needs together for risk reduction, acuity, efficiency and quality management, as illustrated in WHO's Cohorting Layout <ref name="Layout3"/>

=== Workflow ===
Within individual functional zones, the workflow activities can be arranged to proceed from clean procedures to contaminated procedures. In the example below, the staff arrival, PPE donning, doffing and patient flows are worked to have controlled interaction and minimised cross-over

<gallery mode=packed heights=400px >
ACS HCW Flow.png |ACS Health Care Worker Flow
COVID-19 Workflow in small unit.png |COVID-19 Workflow in Small Testing Unit <ref name="Western Cape Provincial Government, 2020b>Western Cape Provincial Government, 2020 b</ref>
COVID-19 Workflow in large unit.png |COVID-19 Workflow in Large Testing Unit <ref name="Western Cape Provincial Government, 2020b"/>
</gallery>

As far as possible, a single direction flow of clean to dirty is recommended for all processes: support services, supply and waste.
The Small ACS unit workflow diagram<ref name="Western Cape Provincial Government, 2020b"/> illustrates the recommended separation of access and exit, separate waiting seats, for persons who may be COVID-19 infected. Separate spaces are provided for donning and doffing PPE. Staff change areas are provided.

In the Large ACS unit workflow diagram <ref name="Western Cape Provincial Government, 2020b"/>, there is a clear separation between staff areas and patient areas. Waiting seats are set far apart to reduce transmission risk. Staff change rooms are provided near the point of entry to the facility for staff to change from street clothes into medical work clothes. To prevent work clothes worn inside the facility from contaminating street clothes, these are kept in separate lockers. A step-over barrier from dirty to clean sides of the change room is helpful to enforce a mind-set of avoiding cross-contamination. Bins for contaminated garments are to be provided in change rooms. Shower facilities are to be provided for staff.

== '''Operational Strategies''' ==
=== Cleaning, disinfection and decontamination ===
Surface and substrate specification, and detailing of all areas should, as far as possible, allow for frequent:
*Cleaning with detergent and water.
*Disinfection with 75% alcohol solution (metal surfaces).
*[https://en.wikipedia.org/wiki/Sodium_hypochlorite Sodium hypochlorite] (1,000 ppm)/ Household bleach.
*Disinfectants listed on the EPA List N<ref>The United States Environmental Protection Agency, [https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 List N: Disinfectants for Use Against SARS-CoV-2 (Last Visited 2020) ]</ref> (for non-critical environmental cleaning).
*High-intensity ultraviolet surface disinfection (UV-C).
*Decontamination and sterilisation of clinical equipment.

=== Goods and waste management ===
Remove any unnecessary furniture, equipment and paraphernalia from all patient care and clinical areas. Provide a clear, secure space for waste management. Any potentially infectious waste materials generated at the ACS should be considered and treated as medical waste (health care risk waste). The applicable legislation is:
*[https://www.gov.za/sites/default/files/gcis_document/201409/35405gen452.pdf The National and Provincial Health Care Risk Waste Management Regulations].
*[https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf National Department of Health COVID-19 Environmental Health Guidelines.]<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>
Waste disposal bins should be positioned near the exit inside each patient rooms or wards to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another patient in the same room.

=== Materials and finishes ===
Floor materials must be:
*Level,
*Free of dust and oil,
*Impervious and smooth,
*Slip-resistant in wet areas (e.g. patient ablutions).
Smooth, cement screed floors are acceptable. Where hosting facilities have carpeted areas, a risk assessment of factors such as durability, hygiene and decontamination needs to be conducted. In cases where the acceptance of carpeted flooring is contradicted (but other factors make it a compelling option), temporary floor finishes or covering can be investigated.

== '''Personal protection''' ==
=== Hand sanitation ===
Where wash-hand basins are not provided, clinical wash-hand basins should be installed, at the minimum rate of provision of one wash-hand basin per 5 beds. Clinical wash-hand basins (see figure below) have a variety of features not present in standard wash-hand basins, which are preferable for infection prevention and control. Where standard wash-hand basins are provided, an upgrade is not necessary. In all cases, there should be no surfaces and no clutter, equipment or supplies in the vicinity of wash-hand basins, including surgical gloves.
<gallery mode=packed heights=400px>
Clinical hand wash basin.png|Handwash Basin <ref>de Jager 2020</ref>
Portable Wash-hand Basin.png|Portable wash hand basins can be provided in ACS <ref name="BDPa">BDP 2020, NHS nightingale instruction manual, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf</ref>
</gallery>

Where wash-hand basins are not available, portable units can be used, as shown above<ref name="BDPa"/>. Mounted brackets for hand sanitisers are to be provided for every two beds, preferably mounted near the foot rather than the head of the bed and at all common touch points such as entry points at ablution facilities, linen room, sluice, storerooms, medicine rooms/cupboards, near refrigerators, telephones, light switches, at entry/exit doors, etc.

=== Personal protective equipment ===
Donning and doffing points for personal protective equipment, and convenient, safe disposal of consumables to be placed at critical key points when entering patient areas.
----

== '''General transmission mitigation''' ==
=== Water and sanitation ===
To comply with National Building Regulations; Hazardous Biological Agents Regulations and National Department of Health COVID-19 Environmental Health Guidelines<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>.

=== Droplet aerosolisation ===
When designating areas for procedures during which aerosolization and airborne transmission risk is high, the building ventilation must be carefully considered to take into account downstream risks. In particular, consider to where potentially contaminated air, arising from aerosol-generating procedures, is exhausted. In general, air exhausted directly to the outside is diluted and considered safe, unless there are openings to occupied spaces near the exhaust air outlet. 

In the event that potentially occupied spaces will receive partially diluted or undiluted contaminated air, or where this is indeterminate, the aerosolising activity should be designated to an alternate area. In the event that an alternative is not available, some treatment regime (air filtration or air disinfection) is necessary. 

In most naturally ventilated settings, the airflow direction between zones may fluctuate according to the wind direction. Such high-risk spaces should not be adjacent to spaces with high susceptibility rates, such as PUI areas and uncontaminated areas. Contaminated areas should not be directly adjacent to clean areas unless mechanically ventilated. 
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|Guidance on COVID-19 building ventilation design is provided here]].

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Health, Safety and Well-being''' ==
In addition to the infection prevention and control measures discussed above, the following should be provided for health, safety and well-being.
=== General provisions ===
*Minimised and controlled entry and exit points, with suitable control.
*Clearly identified accessible and marked routes for patients, staff, goods and waste.
*Clear designation of restricted zones.
=== Site level provisions ===
*Safe staff parking and arrival of staff via planned and public transport.
*Clearly demarcated parking for people with disabilities.
*Arrival and departure point for patients via public transport, passenger vehicles, and emergency service.
*Limited safe patient parking.
*Supply of goods and removal of waste.

=== Within and between buildings ===
*Entrances with a clear opening width (CoW) of at least 900mm.
*Routes with a minimum width of 2 000mm free of hazards, for example, rubbish bins.
*All clinical, patient and support areas to be accessible by trolley.
'''Ramps''' should be of stable construction, capable of sustaining a mass of 300kg. They should incorporate side lips and the surface should be slip-resistant. Gradients should be as gentle as the circumstances allow. (Recommended maximum 1:20). 
'''Small changes in floor levels''' are not desirable, but where these exist are to be clearly marked with reflective paint/ tape, and lit at night
Elevators between different floors, where patients need access (The recommended minimum lift size for patient trolley/stretcher movement is 1 400mm × 2 400mm, however, this may not be possible). 
'''Pathways''' to be lit at night, where used at night. 
'''Staircases''' must be well-lit at night with non-slip surfaces and secure balustrades. 
'''Doors''', Double doors and automated or push-operated doors to all clinical areas are to be preferred, where these are newly installed or able to be retrofitted. Door closers are to be disabled, where not necessary to reduce touch surfaces. Hand sanitisers to be provided at where high touch common surfaces occur (e.g. wall-mounted at doorways).

=== Signage ===
The appropriate level of information to facilitate legibility, orientation and wayfinding. Minimum standards, signage to be:
*Clearly visible, simple font, font size, contrasting colours, placed in the field of vision
*Washable
*Comprehensive safety signage - fire signage (exits, equipment etc.)
*Restricted areas clearly marked
*Identification signage - each patient space to be allocated a unique number and a whiteboard or perspex sheet for writing the patient’s name
Signs should be posted immediately outside of patient rooms indicating appropriate IPC precautions and required personal protective equipment (PPE).
Signage of a temporary nature can be provided on laminated white A4 sheets attached eye-level. The text should be black sans-serif (for instance Arial) text at least 40point size and centrally positioned on the sheet. Detailed guidance on signage is provided in IUSS Inclusive environments.
=== Safety and security ===
Upon identification of the ACS host site, a team should be convened to conduct a multidisciplinary safety and security analysis. These critical team members need to form the working committee responsible for undertaking the detailed assessment of the existing facility’s security. They should analyse data about the security system’s condition and review existing security concerns or issues that are reasonably likely to become concerns in the near future. The figure below represents a five-zone approach to security, which is a recommended, systematic approach to security.
[[File:Zonal approach to security.png|center|600px|thumb|IUSS Security- Zonal Approach to Security <ref name="IUSS Security">IUSS Hospital design principles - Security [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file]</ref>]]
The security strategy should take into account that whilst clinical services and some logistical and support services will be required 24 hours a day, seven days per week, some support services, logistics services and auxiliary services may only be operational for the minimum periods required to meet demand. These functional elements should be capable of being secured, for example over weekends and at night, as the case may be.
Detailed guidance is available in [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file IUSS Hospital design principles - Security] <ref name="IUSS Security"/>

=== Comfort and dignity ===
Supplemental heating: Patient health and comfort are dependent on, amongst others, maintaining body temperature. The ACS structural technology must be selected to achieve the general indoor environment conditions discussed in a subsequent section for all clinical and occupied areas. As we are moving into South African winter supplemental heating may be required, especially in the evenings, in order to avoid hypothermia. Use of fans, bar, radiator or gas heaters should be prohibited. Unless clinical areas can be maintained above 18 degrees centigrade, patients should each have an infrared heater available, in addition to blankets. Personal/ donated blankets can be considered if they are laundered first and could be destroyed upon discharge.
Mobile screens should be available to provide privacy where necessary (e.g. during consultations or procedures).
<gallery mode = packed heights = 400px>
Bed_Isolator_-Vietnam.png|thumb|Flexible Barrier Isolator<ref>WHO. (2020), Severe Acute Respiratory Infections Treatment Centre. Geneva, Switzerland : WHO- World Health Organization</ref>
ACS Cohort beds.png|ACS Cohort beds.png|thumb|Excel Centre London 04-2020 <ref>Architects' Journal 2020, [https://www.architectsjournal.co.uk/news/nhs-nightingale-bdp-on-the-first-nine-days-converting-the-excel-centre/10046749.article https://www.architectsjournal.co.uk/news]</ref>
</gallery>
Some solutions which address patient privacy and dignity are depicted above.

=== Notes ===
<references/>

== '''Schedule of Accommodation''' ==
Based on clinical needs of the ACS, a schedule of accommodation can be crafted capturing the clinical, clinical, logistical, support and auxiliary services associated with the render of care. When deriving a schedule of accommodation, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital tool can be used. Functions to be accommodated are: 
'''Clinical services''': Triage, rapid assessment of persons entering the facility, to expeditiously identify and render the appropriate service. Admissions and registration. Inpatient accommodation is to be organised according to cohorting principles, discussed above. Testing and diagnostics, including laboratories and x-ray. Safe storage and dispensing of drugs to patients.Offices for clinical administration and clinical planning meeting rooms in the clean zone are needed. 
'''Logistical services:''' Logistical services will entail management of flows of people, goods, services and information to and from the site, as well as within the site. It includes security and communication arrangements. Staff entry, preparations to transition from outside to clinical work environment, including pause areas for relief. Emergency services, visitors. Goods, supplies and storage and waste removal and/ or treatment.
Support services key to the provision of clinical services should be separated so that the risks associated with that particular activity can be managed. 
'''Support services are:'''
*Laboratory services
*Catering
*Laundry
*Environmental cleaning and housekeeping
*CSSD
*Maintenance and cleaning of surrounds, eg. waste areas
*Porters/”runners”, stretchers/wheelchairs
*Mortuary
* Security
Support services can be provided off-site, in which case, safe, secure and efficient transfer and logistical arrangements should be designed. 
'''Auxiliary services:''' Auxiliary services are services which may be provided on or near the ACS site, but which are not directly related to core clinical care. This included overnight accommodation for staff who may not wish to return home to avoid exposing their families, or who need rest between shifts, or for discharged patients awaiting transport home, volunteers who have recovered from SARS-CoV-2.
Limited psychosocial services and allied health services may also be provided on or near ACS for example by approved partners.
Examples of schedules of accommodation for patient and support spaces for a protective isolation ward is available [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedule for COVID-19 Isolation Wards|here]] and mild to severe cases [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedules for COVID-19 Wards for Mild to Severe Cases|here]].

== '''Clinical Services''' ==
=== Triage ===
Confirmed COVID-19 cases and PUIs who are referred from a testing facility or a higher level of care, will enter the facility in a triage area to receive vital screening and initial assessment. They will be registered and admitted to inpatient care. They will be assigned a "ward" or section of the facility - based on disease status and acuity. These are Protective Isolation, the Mild & Moderate ward, or the Critical & Severe wards. Patients should be clustered according to gender. As far as practicable, ablutions for each gender, isolation patients, paediatrics and staff shall be separately provided. Paediatrics patients, if admitted, are to be assigned a dedicated section.
As patients recover or deteriorate, they may be relocated to the appropriate section/ ward.
Once the patient has sufficiently recovered and a negative test result is received they will be appropriately decontaminated and discharged, collecting medication from the dispensary on exit. Patient movement between various sections of the ACS will be restricted as far as possible, with mobile radiology units, in-ward medication dispensing and in-ward food service.

=== Inpatient ACS accommodation ===
Separate spaces for:
*suspected, unconfirmed cases, under observation (PUIs), to be accommodated in isolation facilities (separate rooms, if possible);
*patients with confirmed COVID-19 with mild to moderate disease, not requiring dedicated oxygen therapy;
*patients who require dedicated oxygen therapy;
*patients requiring mechanical ventilation; and
*recovered/ confirmed negative.
==== Protective Isolation Facilities ====
Suspected, unconfirmed cases, under observation – persons under investigation (PUIs) to be accommodated in protective isolation facilities (separate positive-pressure rooms, if possible). PUI are restricted to their rooms. All food and laundry services will be brought to the PUI rooms to reduce interaction and potential contamination. All waste will be collected by facility staff and taken to waste handling areas. Infection prevention and control measures are put in place for the handling of used food utensil and laundry as well as waste collection. PUI areas will have restricted access, including for staff serving other inpatient sections, for confirmed cases.

==== Inpatients accommodation for confirmed COVID-19 ====

Inpatient facilities confirmed positive COVID-19 can be accommodated in large shared ‘wards’ with partitioning between patients. Partitioning between patients is optional. Partitioning is preferable to curtains found in conventional hospitals, as they are more conducive to daily cleaning. If curtains are used, antimicrobial treated fabrics with biocide used to treat the curtains has been tested to international standard EN 14476 and shown to be effective against H1N1 Influenza A Virus (Swine Flu), >99.999% kill rate in 5 minutes and measles morbillivirus, >99.99% kill rate in 5 minutes are preferred. If only separate rooms are available, patient monitoring and surveillance will need to be accommodated. This phase of treatment has a lower area/space requirement compared with PUIs, as cross-infection between patients is less of a concern. Shared ablution facilities are acceptable. It is recommended that, at least, two general accommodation ward areas be provided. 

a) Mild and moderate patients, and 
b) Serious and critical patients. 

The room must have openable windows for natural ventilation if a dedicated positive pressure ventilation system is not available. Ducted ventilation systems shall not be shared between PUI areas and confirmed COVID-19 patient areas. 
[[File:COVID-19 ACS - protective isolation – bed layout.png|thumb|center|800px|ACS - protective isolation – bed layout]]
[[File:COVID-19 ACS – mild-moderate patient bed layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient bed layout]]
[[File:COVID-19 ACS – mild-moderate patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient shared ward layout]]
[[File:COVID-19 ACS – severe-critical patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – severe-critical patient shared ward layout]]

Examples above show bed layout with bed spacing for protective isolation, a mild/moderate patient and a mild/moderate patient shared ward and for a severe/critical patient

=== Patient services ===
Patients in ACS will not generally be ambulatory and will be confined to their room, or cubicle in a bed. In general, domestic beds or hospitality industry (hotel) beds are not suitable for patient care. These should only be used where a hospital-grade bed cannot be sourced, as hospital beds are designed for ease of cleaning and decontamination (for infection prevention and control) and with patient and ergonomics, safety and comfort taken into account (they prevent back injury for nursing staff and can help to prevent bedsores). The higher the specification of bed, the more suitable it is for the higher levels of care. Lockers for patients personal belongings should be provided in the uncontaminated zone (in which case bedside lockers will not be necessary), and it is preferable (where bedside lockers are not provided) for overbed tables to be provided, per bed, if possible. 
The following beds are suitable:
*Repaired and refurbished beds from condemned hospital stocks.
*South African National Standard, SANS 521:2013 Edition 3.5, on Hospital beds and cots ISBN 978-0-626-28830-3.
*Beds listed on the National Treasury (See [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Hospital Bed Specification|specification]]).
The table below details the minimum services required at each patient bed. Details on these services are discussed in a subsequent section of the document.

{| class="wikitable"
|-
! Service/ Capacity!!Triage!!Isolation !!Mild – moderate inpatient!!Severe case wards!!Critical case wards
|-
| Power – 16A 230V Single socket outlet||As needed ||1 per bed||1 per bed||3 per bed||6 per bed
|-
| UPS Power – 16A 230V Single socket outlet ||As needed||1 per bed||1 per bed||1 per bed||2 per bed
|-
| Medical Air<ref group="Note">Mobile units recommended for intermittent use. 3 per 20 beds</ref><ref group="Note">There are some ventilators which have built-in compressors allowing them to function without Medical Air. This is however, not the norm. With Ventilators probably being the most difficult medical device to obtain at present, it would be prudent to rather allow for Medical Air at each bed.</ref> (LP)400kPa||No||Yes||No||Yes||Yes
|-
| Medical O2 -400kPa||Portable/shared||Portable/shared||No||One||Two
|-
| Vacuum-40kPa||No||Portable/shared||Portable/shared||Yes||Yes
|-
| Equipment rail||||||||Yes||Yes
|-
| Upper room UVGI||Optional||Optional||||||Optional
|-
| Examination light||No||No||Yes||Yes||Yes
|-
| Room Ventilation rate||60 L/s per person||10 L/s per person||10 L/s per person||10 L/s per person||12 ACH
|}
'''Notes: '''
<references group="Note" />

Two additional 16A 230V single socket outlets, one two-pin outlet and a worktop should be provided for every 32 beds (or part thereof), for:
*Electrocardiograph (ECG): Could be omitted if monitors have a full 12 lead ECG function.
*Blood gas analyser: Could be omitted if a Lab Services are available.
*Staff cellphone charging.

Example of healthcare technology to be provided for critical care patients is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]. Severe patients may be provided continuous positive airway pressure (CPAP). Emergency trolleys (“crash carts”) are to be provided in patient areas with convenient access to patient beds, out of the passage of corridors and is moved to the patient when needed. 1 crash cart for every 16 patients (or part thereof, with at least one dedicated for PUIs. An example of provisions for a crash cart is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]
==== Patient ablutions ====
[[SARS-CoV-2 is found in faecal matter]], so careful management of patient body fluids is crucial and convenient, practical support for frequent cleaning of ablutions especially shared ablutions is necessary. Dedicated ablutions (toilets and showers) are to be provided for patient use. Toilets and showers should be in separate rooms.
Hand washbasins and or/ hand sanitiser should be provided both inside and outside the toilet room so that patients can wash their hands on the way in and on the way out of the room.
*1 toilet for every 8 persons.
*1 shower for every 8 persons.
*1 disabled ablution for every 8 regular ablutions (or part thereof).
*1 disabled shower for every 8 persons (or part thereof).

Critical and severe patients may be sedated and have a reduced need to access ablutions, ablution facilities proximity and provision can take this factor into account. Showers and wash hand basins should have hot and cold running water. Where possible ablution facilities must have openable windows for natural ventilation, if not possible the bathroom extraction and room ventilation system must be reviewed before admitting patient '''(see [[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|ventilation]]).'''

Portable toilets and showers may be used, provided that suitable hand wash facilities are provided. These will need to be suitably located, preferably in decentralised clusters, so that patients can easily access them without needing to walk very far. Ablutions should be located and designed in such a way as to provide visual and acoustic privacy, dignity and avoid disturbance of other nearby patients when accessing, using or cleaning the ablutions. Separate ablutions are to be provided for PUIs and confirmed patients.

====Makeshift sluice areas ====
In conventional hospital settings, sluice rooms are provided for cleaning and sanitation of soiled equipment, such as bedpans. In a temporary setting, such as an ACS, the establishment of a temporary sluice room may not be practicable, and there may not be facilities for emptying buckets, rinsing equipment etc.. The following is suggested:
Allocate a toilet, hand wash basin, not in splash range and restrict access to it for draining buckets and install a macerator for disposal of disposable bedpans. Electrical, water and waste supply points required as per supplier specification.
==== Dedicated patient treatment areas ====
The following dedicated, private spaces per ward for clinical procedures are recommended:
*Counselling and consulting room (can be shared), as shown in the figure below
[[File:Consulting room example layout.png|400px|thumb|center|Consulting room example layout]]
*Minor procedures room, as per the example provided in the figure below 
[[File:Treatment-minor procedures room example layout.png|400px|thumb|center|Treatment / minor procedures room example layout]]

== '''Logistical Services''' ==
=== Communications ===
Electronic communication should be facilitated in all zones of the ACS by the provision of device charging stations, and wifi.
=== Visitors entry point ===
Visitors are strongly discouraged from entering the ACS.
*In paediatric wards, one parent may be accommodated to visit a patient. In such cases, direct access for the visitor should be provided so that the visitor does not need to pass through the general patient area. Appropriate PPE must be donned before entering the patient area and hand washing/sanitising must be done when exiting the area.
*Non-patients who are accompanying suspected patients to the facility for testing or admission must be accommodated in a well-ventilated, spacious waiting area. Signage in such waiting areas must inform visitors about symptoms, hand hygiene and PPE.
*Hand washing/sanitizing facilities should be provided.

=== Staff areas ===
==== Staff change rooms ====
A minimum of 9m² or 4m² for a single person, increasing by one m² for each additional person is required. The clean (street side) and dirty (contaminated facility side) of the change room should be separated by a step-over barrier.

==== Staff rest areas ====
Staff rest areas within the main facility should be provided with access to kitchenette facilities and staff ablutions.
=== '''Staff auxiliary services''' ===
'''Staff on-call:'''Since staff may be required to work long hours or could be required to be on-call, shared, overnight sleeping facilities can be provided for staff on duty, outside the contaminated area, but in close proximity on the patient areas. An example is set out in the diagram below.
[[File:Example of on-call sleeping area for staff.png|center|600px|thumb|Example of overnight sleeping area for staff]]

'''Staff accommodation:''' It is advisable to provide some staff accommodation for off-duty staff who may not have suitable alternatives, for example homes too far away, transport limitations or the requirement not to expose family members to risk. This should be provided in the vicinity of the ACS, but in a physically separated zone. This amenity can be outsourced.

== '''Support Services''' ==
=== Workflow principle ===
[[File:Linen processing cycle.png|none|thumb|Linen processing cycle <ref>IUSS 2014 [https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department]</ref>]]
Progressive workflow from “dirty” (that is contaminated) to “clean” linen is advisable to reduce the risk of exposure to contaminated materials. The workflow diagram below, showing the progression from the dirty linen receiving area, to the cleaning process, to decontamination and drying, and finally sorting and packing, and storage, illustrates this principle.
=== Laboratory ===
[[File:Example of modular laboratory.png|right|thumb|Example of modular laboratory]]
The WHO recommends the following laboratory diagnostic equipment be accommodated:<ref>WHO 2020, [https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items]</ref>.
<nowiki>• Lab screening test kit
• Lab confirmation test kit
• RT-PCR kit
• Extraction kit
• Cartridges for RT-PCR automatic systems
• Swab and Viral transport medium
</nowiki>
Additional accommodation requirements are:
# Reception counter- receiving specimens
# Testing with perspex/ glass screen
# Receiving/Data capture
# Specimen holding
# Toilet - staff
# Blood storage fridge
Can be provided as a modular laboratory unit as shown in the diagram.
=== Pharmacy ===
The purpose of the pharmacy is to provide medicines needed for inpatient treatment and care.
All medical supplies should be stored in a secure, climate-controlled area in close proximity to the patient treatment area. The pharmacy must have dry, lockable, climate-controlled storage of medications. Most pharmaceuticals are labelled with storage temperatures. The pharmacy should have adequate ventilation through an openable window to prevent humidity from building up in the room. Air-conditioning or mechanical ventilation can be provided, if necessary.

Dispensing areas must be well lit. Worktop in space for stock records and administration. Dispensing counters to have perspex or glass screens to serveries. Social distancing implemented at counter, between pharmacists/assistants and between chairs in waiting area.

Can be provided in a mobile unit.

=== Radiology ===
The purpose of radiology services is to provide chest X-Ray services for COVID-19 diagnostics. In general, CT scans, bucky rooms etc. associated with some radiology equipment require specialised infrastructure and therefore is not suitable for ACS. Radiology services can be provided as a mobile floor standing unit, or containerised unit. Alternative technologies such as Lodox and hand-held ultrasound devices are being investigated as potential options and could be confirmed as suitable for use in due course.
=== Laundry services ===
All dirty linen should be handled for bagging or binning inside the patient room/cohort area. The clean linen stock should be stored conveniently close to clinical areas, in a dedicated clean area in the uncontaminated zone. Used linen should be stored in a designated, safe, lockable holding area while awaiting collection. Interim storage areas for soiled linen at the wards is allowable; this may be in dirty linen/ utility room.
Any clean linen for PUI areas should be handled in spaces physically separate from dirty linen of confirmed patient areas. It may be necessary to completely separate PUI and confirmed patient linen streams. Soiled linen and clean linen bags and bins should be dedicated and not mixed.
Full laundry cleaning and drying services may be provided on-site or outsourced. If laundry cleaning and drying services were already rendered on or for the host site before it is repurposed as an ACS, then a suitability and risk assessment should be conducted to ensure that the volumes of laundry generated and infection prevention and control measures are conducive and modifications made as necessary. A new full laundry service may take time and resources to establish, and in general, will not be established at a host site as a temporary solution. Where the site and circumstances advocate for the design of a new laundry or the upgrade of an existing laundry, the IUSS Laundry Services for Hospitals should be applied.
==== Siting and model selection considerations ====
When an existing laundry is being assessed for use or a new one is being planned the following considerations apply:
* Water and power capacity.
* Ease of access to the ACS’s main corridors and internal transport routes.
* The noise factor of the facility and its impact on nearby patient care departments.
For outsourced departments:
* Delivery areas to allow sufficient space to ensure that vehicles can manoeuvre and park easily at the reception and dispatch bays.
* Access to the ACS service roads and public roads.
==== Functional requirements ====
The most basic equipment needed in a laundry includes washing machines, tumble dryers and ironing machines. Equipment requiring steam is not recommended for a temporary facility. The sizing of the laundry, equipment and engineering services can be modified based on the principles provided in the IUSS Laundry and linen.
=== Catering services ===
Kitchenettes, that is, areas for tea, coffee and snacks, mainly for staff, in staff pause areas are discussed elsewhere in this document.
Catering services (for staff and patients) may be provided on- or off-site. If the ACS is to be established with easy access to a suitable, existing, functional kitchen service (e.g. hotel, military or hospital catering) which can meet the additional demand of the ACS, then this should be used. If there is no suitable facility, catering should be outsourced via a suitable off-site supplier. Only in the event that no feasible or suitable, existing facility or local supplier is available, should a new catering service be established at the ACS. Detailed guidance for the sizing, design and layout of catering services can be found in the IUSS Catering Services for Hospitals.
The kitchen (for on-site catering) or preparation area (for off-site catering) should be located with easy access to the point of delivery and storage of food. Adequate food and equipment storage space must be provided.
It is recommended that patient and staff meals, where provided, be supplied in disposable, containers, suitable for incineration, and that these are disposed of as risk waste immediately after use.
Where off-site catering is used, a suitable area for receiving should be provided. Space will be required for sorting meals for distribution and collecting and storing dirty dishes, washing dirty dishes, if necessary, and disposing of left-over food and disposable containers and utensils. The size of the areas required for this will depend on the number of meals delivered.

=== CSSD ===
The primary function of a Central Sterile Supply Department (CSSD) is to provide an efficient, economic, continuous and quality supply of disinfected and sterilised items, when needed, to all patient-care service points in the ACS, and to receive returned contaminated items for cleaning.
CSSD with limited sterilisation capacity (autoclave) but sufficient disinfection capacity (instrument washing). The layout requires a designated clean and dirty areas with a hard barrier between to avoid cross-over of staff and equipment. Work is unidirectional - flows from dirty – to clean - to sterile areas.
This yields three distinct zones:
1. Receiving and cleaning with pass-through windows
# Dirty receiving with Perspex or glass partitioning
# Dirty utility
# Decontamination and cleaning/wash area with throughput instrument washing
# Trolley wash/Park – external
2. Inspection, assembly and packaging with pass-through windows
# A tabletop autoclave
# Instrument washer
# Clean Packing area
3. Sterile processing, storage and distribution. (Separate issuing area from receiving area) with pass-through windows
# Store -linen and consumables
# Sterile pack store
# Issue - Collection hatch with Perspex or glass partitioning
Must also have a secure, separate receiving area for consumables receiving and storage.
An example of a CSSD unit is shown in Figure 21.T

[[File:An example of a small CSSD facility.png|600px|thumb|none|An example of a small CSSD facility<ref>IUSS 2014, https://www.iussonline.co.za/norms-standards/support-services/24-central-sterile-service-department</ref>]]

To be understood: Quality of services, eg. water (including a source of distilled or ionised water for rinsing of bronchoscopes) and electricity, quality of management, if equipment is appropriate for needs and fit for purpose, what is required of the equipment in the near and far future (relocation?), compliance with S.A. National Standards for CSSD, compatibility of equipment and devices, correct chemicals, maintenance of equipment, training of operators. Although the use of disposable breathing circuits and accessories (masks) should be encouraged, the capacity to disinfect these items if disposable is not available must be considered.

The CSSD must be sized to serve the ACS. Considerations are workload and space requirements. CFSA has extensive [https://www.fidssa.co.za/Content/Images/CFSA_SOP_2018.pdf standard operating procedures] for CSSD.

Workload: Number and type of procedures, number of procedure rooms, eg for bronchoscopy, operating hours, available inventory, volume of work and peak times, degree of mechanization, eg. manual or automated instrument washing, amount of product to be stored – chemicals, barrier wrap, chemical indicators, etc., storage and distribution records, quality records – eg. equipment checks, disposal needs.

Space requirements: Space for separation of clean and dirty, allow for unidirectional movement, allow space to manoeuvre trolleys (queue, pack/unload), reduce lifting and carrying heavy items, reduce awkward movements, allow for tidy work areas. Insufficient space will compromise sterility!

Preference should be given to construction materials and finishes which are suitable for frequent cleaning and tolerant to chemicals, including bleach (sodium hypochlorite). Impermeable flooring, non-slip and smooth washable walls are needed. Joints at walls and floors and coving at wall edge, and exposed drains should be avoided. Worktops should be sealed and should be ergonomically suitable.

Ceiling heights below 2.8m may be vulnerable to damage from humidity Where steam and moisture are generated. Noise – insulation of washer-disinfector and steriliser in technical walls will reduce noise. Lighting: Natural light if possible – windows sealed. High luminance if artificial lighting. Open, slatted shelves for sterile store area. Sinks for manual washing: At least two basins, deep (25cm at least) basins, 91 cm from floor, wide and long enough for the biggest instrument tray or container, water ports for flushing of lumens.

The CSSD space allocation and layout should be determine based on what procedures and which medical devices will be required. A typical [[equipment list is provided here]].

=== Maintenance and cleaning ===
Maintenance and cleaning services must be accommodated with offices located away from clinical areas.

=== Mortuary services ===
The National Department of Health has issued guidance on handling of dead bodies and infectious remains<ref>National Department of Health South Africa, 2020 [https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf]</ref>, which should be applied to ACS. While some guidelines have recommend that bodies of persons who have died from COVID-19 should only be held for a very brief period prior to cremation or treatment for burial<ref>Zhejiang University, 2020 [http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm]</ref>, the WHO holds the view (at the time of writing) that there is no evidence of persons becoming infected from exposure to bodies during normal ceremonial and burial activities. However, appropriate PPE should be used when handling such bodies with additional airborne precautions to be taken during autopsies<ref>WHO, 24 March 2020 [https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf]</ref>.

Either body cabinets or a refrigerated room could be used for body storage.
==== Location and layout of mortuary service ====
It is likely that not all alternative care sites will have a mortuary. Those without a mortuary must have a holding room that is located away from general access areas. This holding room must be suitably sized and conditioned. A recommended room size is 3.5 m x 3.4 m<ref>IUSS Adult Inpatient Services, 2014, [https://www.iussonline.co.za/docman/document/clinical-services/65-adult-inpatent-services-gazetted/file]</ref>
A mortuary should be located so that it is easily accessible to mortuary staff and related service providers and visitors without presenting either aesthetic, emotional or ethical problems for unrelated staff, patients or visitors. It should be separate from the general facility, allowing access for the family to view a body without passing through any potentially contaminated area of the facility. The visitors’ entrance should be external and completely separate from other access points.
Appropriate routes should be designated so that bodies are not moved through public-access areas.
==== Sizing of mortuary ====
The layout and size of a mortuary are largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.
==== Services ====
The following services are required in a mortuary:
* Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.
* Sluicing facilities are to be provided in both the body-preparation and autopsy areas if they are not a common area.
* Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush-fitted stainless steel grids.
* No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.
* The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.
* Anti-backflow devices should be fitted to the water-supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.
* Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.
==== Finishes ====
Wall and floor finishes should be impervious to liquids and easily cleanable.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Environmental Controls''' ==

== '''General Indoor Environment Conditions''' ==

Existing environmental control systems should be modified to suit requirements in the facility. The following issues should be considered:
* Systems should be set to maximise the introduction of fresh air and maintain the pressure regime (see ventilation).
* The following internal temperature range should be maintained 19 - 24oC.
* Cooling systems should be able to cater for projected internal heat gains from people, lighting and equipment. Indicative heat gains in treatment areas are 8W/m2 from people, 15W/m2 from lighting and 3 W/m2 equipment and in critical care areas 16W/m2 from people, 15W/m2 from lighting and 60W/m2 equipment.
*As heat gain can vary widely between items of equipment, heat gain and utilisation rates for equipment should be obtained from the manufacturer to establish this more accurately.

=== Solid waste from ACS ===
According to the National Department of Health COVID-19 Environmental Health Guidelines
“All solid waste from the facility should be regarded as potentially infectious material and therefore appropriate precautions should be taken". The management of healthcare risk waste (HCRW) should follow the correct identification segregation, storage and disposal processes as indicated in SANS 10248-1.

* HCRW is segregated at the point of generation and shall be containerized to minimize the risk of contamination.
* Waste generated from patients in isolation or quarantine in a designated facility health facility is treated as health care risk waste (HCRW) as per SANS 10248-1-2008.
* The HCRW is properly packaged in a sealed, leak and puncture-proof containers/ boxes.
* The HCRW is labelled with the biohazard symbol/ sign and marked “Corona virus or COVID-19”.
* The HCRW is stored separately from other waste generated.
* The collection, transportation, treatment and disposal is provided by only an appointed/ appropriate contractor/ service provider, however, ensure that waste is safely stored until the health care waste management company can pick it up and that the company knows and acknowledges that waste was generated by suspected or confirmed COVID-19.
* The waste management company collecting must ensure that and treated and disposal is conducted at license waste treatment/ disposal facilities .
* All personnel or staff in contact with patients must be geared with appreciate personal protective equipment (PPE’s) at all times to prevent exposure or risk to health.
* Monitoring should be done at such facilities.
* All, bags, bins and boxes must be adequately sealed, as not to leak any fluids, and must be wiped down with 0.05% chlorine solution

Measures developed should consider the following.
* Develop a waste management plan following national guidelines and best practice standards for the disposal of medical waste (WHO, 2020).
* Establish procedures with medical waste service providers to regularly pick up the waste and dispose of this safely.
* Provision should be made for 5kg of solid waste per bed per day and this should be monitored and supplemented where it appears this may be inadequate.
* Ensure that access to waste is secure and controlled, for instance, by using lockable waste 1000l containers kept in a location that can only be accessed by health facility and nominated service delivery staff.
* Vermin control programs must be implemented throughout the site with HCRW collection points prioritised
* Provision for safe cleaning and disinfection of reusable containers should be provided. Cardboard, single-use HCRW boxes are removed from site and incinerated.
* Waste must not be allowed to accumulate or be stored inappropriate or unsecured containers.

== '''Engineering Services''' ==
Engineering services include patient services, ventilation, electrical power, water, medical gases, oxygen, compressed air, vacuum, lighting, and fire safety that support the needs of the patients and medical staff under normal and emergency situations. Good practice standards are provided in:
* IUSS Building Engineering Services<ref name = "IUSSBES">IUSS 2017, [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file]</ref>
* NHS Nightingale Instruction Manual<ref name="BDP2020">BDP 2020, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf]</ref>.
The guidance below draws on these and other manuals and standards. 

=== Building ventilation ===
==== Mechanical ventilation ====
While SARS-CoV-2 RNA has been detected in aerosol form, in experimental mechanical aerosolization studies, it is primarily spread through droplet and contact spread and the potential for airborne transmission is thought to be low.
However, the following advice is provided by ASHRAE regarding HVAC systems in general spaces (not specific to healthcare):
Effective high levels of ventilation must be achieved in the facility. Existing ventilation systems should be tailored to suit internal layouts and requirements and the following measures should be taken.
* Mechanical systems should be set to maximise fresh air supply to the facility. There should be no recirculated air without HEPA filtration or other validated decontamination processes.
* A pressure regime should be established, as shown in figure 2, to 'push' air from clean areas, to dirty areas and then out of the building.
* A clean air supply of over 10 L/s per person should be targeted for odour control.
* Fresh air supply shall not be located near patient beds to avoid drafts in winter.
* Extraction points can be located near patient beds in isolation wards or at a high level in long-stay wards. Short-circuiting of air between high-level supply and extraction is a performance risk in winter.
* Noise from ventilation systems and fans shall be below 45 dBA
* Protected lobbies, internal partitions, door arrangements, fans and extracts should be used to maintain the pressure regime and airflow as indicated in the diagram below.
 

[[File:Ventilation in temporary facilities.png|600px|thumb|none|Ventilation in temporary facilities<ref name="BDP2020"/>]]

==== Natural ventilation ====
The airflow direction between naturally ventilated zones may fluctuate according to the wind direction. This is not of concern within and between contaminated zones where occupants are either protected with mandatory PPE or confirmed to be infected with disease strains similar enough so as not be able to reinfect others. Where levels of occupant susceptibility to an airborne disease is significantly different, the less susceptible areas (such as PUI areas and uncontaminated areas) shall be protected from the naturally ventilated and contaminated areas by mechanical ventilation systems with a capacity sufficient to overcome the expected natural ventilation pressure fluctuations (typically 5-15Pa). Where such mechanical ventilation systems are not feasible or expected wind pressure is too great, zone adjacently must be avoided.

===Ultraviolet germicidal Irradiation===
The application of Ultraviolet Germicidal Irradiation (UVGI) for room air disinfection is well understood and is proven to be effective in the disinfection of microorganisms including M. tuberculosis (TB) in air. UVGI should, therefore, be considered as a valid element in indoor airborne infection control strategy for high volume settings. Studies have demonstrated the importance of good vertical air mixing in the room, and the safety of UVGI application. In areas where UVGI is indicated, the design and development of UVGI systems should be in accordance with the [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]<ref>van Reenen et al,2019 [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]</ref>

=== Electrical power ===
Sufficient and reliable power must be available at the facility for envisaged medical equipment, medical gases, lighting and building ventilation equipment. Power installations for the temporary facility can be divided into three zones as indicated below. These are existing services, the temporary service zone and services in each bay.
The following should be considered by competent engineering professionals.

=== Existing services ===
*Capacity: Evaluate whether sufficient power to accommodate envisaged medical equipment, additional lighting and heating, building ventilation and air conditioning can be provided. If existing capacity is insufficient, investigate if it is possible to route additional power from additional locations/transformers around the site or from adjacent sites.
* Safety: The existing electrical distribution network must be able to supply the required equipment load. If this is insufficient/appears unreliable, identify how this can be supported.
* Resilience: Evaluate back-up power and a UPS capacity against essential services demand. If existing capacity is not sufficient, source and establish temporary service capacity.

=== Temporary service zones ===
*Identify locations for temporary service zones where equipment can be located.
*Ensure that equipment and maintenance access is safe and easy.
*Ensure that all distribution boards, circuit breakers and cables are clearly labelled.
=== Services in each bay ===
*Provide pre-wired power strips/trunking as per bay requirements.
*Check that these include sufficient electrical outlets and service points for envisaged equipment.
*Ensure that trunking will carry required equipment loadings. The IUSS Building Engineering Services Guide can be used to check requirements<ref name = "IUSSBES"/>.

[[File:Layout_of_power_in_a_temporary_installation.png|600px|thumb|none|Layout of power in a temporary installation <ref name="BDP2020"/>]]
----

=== Water ===
Water points are needed for handwashing, showers and cleaning. The following issues need to be taken into account.
==== Supply ====
Onsite cold water storage, dedicated to the domestic water requirements of the facility, should be provided. A minimum usable volume of 500 litres per bed should be available.
Hot water storage and consumption should be confirmed by an engineer, as follows:
*Storage 25 L per bed.
*Consumption 180 L/bed.day W/O laundry; 250L /bed. day W laundry.

==== Handwashing ====
See infection control for clinical wash-hand basins
==== Showers ====
Showers for staff coming off shift should be available. Staff flow routes exiting contaminated treatment areas should pass through gowning and shower areas.
----

=== Medical gases, oxygen and vacuum (suction) ===
Medical gases, oxygen and vacuum services will be required in the facility. Mobile gas supply requires piping between supply and patient and clutter floor space. Preferably used fixed installations for patient rooms/cubicles, if possible.

System capacity and point of use pressures and consumption rates are to be ensured at all points. WHO provides technical guidance on [https://www.who.int/publications-detail/oxygen-sources-and-distribution-for-covid-19-treatment-centres oxygen sources and distribution]. 
[[File:Medical gas service layout.png|6oopx|thumb|Medical gas service layout<ref name="BDP2020"/>]]
The following points should also be taken into account.
* For centrally supplied medical gas and vacuum services, system resilience and availability must be ensured.
* Compressors, tanks, accumulators, VIEs, headers and controllers must be secured from uncontrolled access.
* Where possible, gas piping should be reticulated below floors or in ceilings to ensure protection from tampering, damage and ease of access.
* Where reticulation is within open areas, high-level reticulation with point-of-use droppers is advised. Low-level reticulation within rooms is to be avoided.
* Flexible piping can be used, ensuring it does not present a contamination or fire risk and should comply with local regulations. Special care should be taken with flexible O2 piping, keeping it to a minimum.
* Vacuum piping may be contaminated, where point-of-use filtration and collection systems fail. Precautions should be taken when demounting or disconnecting temporary vacuum lines.
* Ensure that oxygen pipelines are designed to provide sufficient flow to all oxygen points in the facility. In terms of utilities, oxygen and medical air would be required. A temporary vacuum point can be provided by mobile medical vacuum units distributed throughout the unit.
* Mobile medical air supplies should be considered where reaching piped specifications are not feasible. Where flexible hoses are used for oxygen and medical air special precautions need to be taken. Flexible oxygen piping must be chemically safe for O2 use. Where perishable flexible piping is used for medical air, terminal filtration at the point-of-use may be required at point-of-use. Especially for long-term use.
* Electrical and gas services can be reticulated against pipe racks or boards fixed to the bed-heads for head to head bed arrangements.
* Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.
* Gas service outlets to be labelled and colour-coded with 3mm lettering.
* SANS 7396-1 should be used to specify the requirements from design to commissioning of medical gas and vacuum systems.
* Medical gas and vacuum pipelines shall be marked per SANS 7396-1 and ISO 5359, as applicable.
* Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.
* SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.
* Plain-ended copper tubing for low-pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.
* Laboratory gas taps and valves shall be marked as described in SANS 10140-4.

=== Lighting ===
Existing lighting systems may need to be modified to suit the clinical requirements in the facility. High bay lighting presents inadequate colour rendering quality for the accurate detection or easy diagnosis of certain clinical conditions. This needs to be evaluated in the selection of supplementary lighting systems.
*Lighting levels should be provided in line with the indoor lighting levels recommended in the Table 6 of IUSS Building Engineering Services .
*Mobile task lighting systems may be adopted in the serious and critical stay wards to supplement incorrect lighting quality.
*Emergency lighting and illuminated emergency egress signage should be linked to the back-up power system.
*External security lighting in external parking areas and spaces around the building should be enhanced to ensure the security of medical staff who need to change shifts at night.

=== Fire safety ===
A functional fire alarm system should be available to support the patient care setting. Fire is a very real threat due to the possibility of an oxygen-enriched atmosphere developing so ventilation is crucial.
The use of temporary facilities for medical care should note the following fire risks (NHS, 2020):
*Patients may have a very high dependency.
*Areas are not specifically designed for patients and do not meet guidance on fire compartmentation and progressive horizontal evacuation.
*Large numbers of patients supplied with oxygen up to 10 litres per minute.
*Possibility of oxygen concentrations exceeding those generally found in the atmosphere- less risk if effective ventilation or large volume i.e. high ceilings.
* Possibility of storage, in excess of 40 litres, of alcohol-based chemicals (such as hand-rub), necessitating a flammables cabinet on site.
*Staff who may not normally work together .
*Staff who may not be familiar with the area.
*Staff not trained in fire safety, progressive horizontal evacuation or oxygen isolation for the specific area.
These factors should be taken into account in fire risk assessments which should then address significant findings in an action plan. Fire assessments should be undertaken by a qualified person and shared with operations and building management staff within the facility. Measures developed should include:
*An automatic fire detection system
*An emergency egress plans are prepared that include patients who have a very high dependency.
*Signage, notices and lighting are installed and are working effectively.
*Management processes are in place to minimise the risk of fire from ignition sources, fuels and oxygen.
*Staff are trained and a fire safety guide sheet for staff is developed and issued.
*Emergency egress routes are kept clear.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Additional Resources''' ==
=== [[Directory of Service Providers|A Directory of Service Providers can be viewed here]] ===

=='''References'''==
<references />

[[Category:COVID-19| ]]
[[Category:Alternate Care Sites|Alternate Care Sites]]

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[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19|(Return to Top)]] 
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Infrastructure Guidance for COVID-19/Alternate Care Sites

2020-05-08T08:40:02Z

Peta: /* Typology dictates & case studies) */

[[Infrastructure Guidance for COVID-19|Return to Infrastructure Guidance for COVID-19]] 

== '''Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19'''==

This guidance work was initiated under the project titled: 
''Reducing Nosocomial and Community-Acquired Tuberculosis by Strengthening the Capacity of the South African Department of Health to Improve Implementation of Infection Control and Waste Management at All Levels of the Health System Under the President's Emergency Plan for AIDS Relief (PEPFAR)'' 

== '''Purpose and Approach''' ==
The global pandemic of COVID-19 caused by the coronavirus, SARS-CoV-2 is likely to result in a surge in need for medical care for Severe Acute Respiratory Syndrome (SARS) in South Africa. Considering the course of the pandemic in other countries, it is anticipated that South African hospitals will not have sufficient capacity to cope with the surge of persons requiring medical attention and that surge capacity via alternate care sites (ACS) will need to be established.
Surge capacity, contemplated here is not the frequent emergency department overcrowding experienced by healthcare facilities (e.g. Friday/Saturday night emergencies) or local casualty emergency that might overcrowd nearby facilities and have little to no impact on the overall healthcare delivery system. It is when a catastrophic event occurs and the affected population seek medical care from existing local healthcare facilities, causing healthcare infrastructure to become exhausted due to excess in demand. During a healthcare surge, the standard of care will shift from focusing on patient-based outcomes to population-based outcomes, and providers should anticipate “a shift to providing care and allocating scarce equipment, supplies and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals.”<ref>[https://asprtracie.hhs.gov/technical-resources/resource/491/altered-standards-of-care-in-mass-casualty-events Health Systems Research Inc., 2005]</ref> 

Surge capacity can be temporarily established in non-traditional environments, such as hotels, exhibition halls, community halls, and as field hospitals, on open spaces. 

In the context of this document, a quarantine site is a facility for patients who do not require continuous professional medical care, while an ACS is defined as a temporary facility that can provide continuous medical care for SARS. This document provides principles and considerations, high-level guidance for minimum requirements and examples for ACS. 

While an extensive set of health facility guidelines does exist<ref>[https://www.iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-servi IUSS Building Engineering Services (2017)]</ref>, these are applicable for conventional facilities and thus include services and guidelines that are not necessarily relevant to the treatment of a novel, highly infectious pathogen, with pandemic effects. Moreover, these do not provide well for the rapid and temporary establishment of facilities. 

In order to formulate high-level guidance, [[as invited by Business for South Africa]], the team reached out to professional industry bodies for inputs, in particular the South African Institute for Architects (SAIA), The Gauteng Institute for Architects (GiFA) [https://www.gifa.org.za/ Gauteng Institute for Architecture] and the [http://www.safhe.co.za/ South African Federation of Hospital Engineering (SAFHE)], by inviting input via a 36-hour research charrette. Relevant historical and contemporary literature was consulted, precedents identified and critically reviewed. An interaction with the team at Wuhan responsible for makeshift hospitals and emergency infectious diseases hospitals, Central-South Architectural Design Institute, was arranged with assistance of the Chinese Embassy. Material from the [[Infrastructure Unit System Support|Infrastructure Unit System Support (IUSS)]], international literature and guidance and input gathered from the broader architectural, engineering and healthcare professional communities was synthesised and moderated by the CSIR team. The draft was reviewed by an expert review panel. 
=== Acknowledgement of contribution ===
The contributions to the initial version of this were gratefully received. [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Acknowledgements|A list of these contributors can be viewed here.]]. 
New contributions are eagerly encouraged along with debate and discussion on the [[Talk:Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites|'''discussion forum.''']] tab above.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Scope and Assumptions''' ==
ACSs as discussed in this document are dedicated, temporary facilities for triage, testing, diagnosis, further referral and treatment of persons:
*suspected of having contracted SARS-CoV-2, (persons under investigation (PUIs)), who are symptomatic and/or are awaiting results,
*or are confirmed to be infected.
ACS will accommodate a variety of clinical, logistical, support and auxiliary services associated with the render of care. ACS will currently not be licensed to provide healthcare services. Since the ACS will operate in a non-healthcare facility, it cannot fully replace a hospital setting and its prime objective is to manage the patient load until the local healthcare system can meet demands. 

=== Exclusions ===
Quarantine facilities are accommodation facilities where a member of the community can remain for the duration of their isolation period. This is typically temporary housing for a cohort of people who do not need intensive medical attention but who cannot stay at home. Patients can take care of themselves and need limited monitoring by medical staff. Quarantine: Containing presumptive-case patients from each other and the general population.
Quarantine facilities – that is for asymptomatic persons who are in the community in self- or imposed isolation, but not displaying symptoms, or who are symptomatic, but are able to safely recover without clinical intervention and do not need continuous medical observation are not considered in this document.

=== Service regime ===
The following assumptions are made with respect to services under consideration.
* Temporary - limited to the part of the pandemic when the “conventional” hospital platform cannot meet demand. To be dismantled, thereafter.
* Uncomplicated, dedicated COVID-19 care is to be prioritised for ACS.
* Patients with comorbidities, paediatrics will be prioritised for conventional facilities, and only accommodated in ACS as a matter of last resort.
* 24 hour, 7 days a week operations. 

=== Assumed mechanism of transmission ===
Transmission of SARS-CoV-2 is understood to be from person to person firstly by [https://en.wikipedia.org/wiki/Transmission_(medicine)#Droplet_infection droplet] transmission, then by the [https://en.wikipedia.org/wiki/Transmission_(medicine)#Direct_contact contact] route and finally via airborne [https://en.wikipedia.org/wiki/Transmission_(medicine)#Airborne_airborne transmission] during or following mechanical aerosolisation. Water transmission risks are minor, occurring in special [https://en.wikipedia.org/wiki/Transmission_(medicine)#Fecal%E2%80%93oral Fecal-oral] circumstances. Reclassification of transmission mechanisms may nullify some of the approaches presented in this guidance. 

=== A call for strategic coordination ===
This document focusses on infrastructure requirements. These provisions are meaningless without staffing, equipping and resourcing. Whilst staffing, equipping and resourcing are not the focus of this document, these are likely to emerge as key constraining features. Resource constraints are likely to become acute during this pandemic. Doctors and nurses are already in critical short supply in South Africa and internationally, and are themselves susceptible to COVID-19 infection. Equipment and consumables are in short supply with heightened global demand, reduced manufacturing capacity and limits in trade flows. This necessitates strategic coordination, proactive planning, options appraisal and prioritisation. 

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Status Quo''' ==
=== Rationale and transmission status ===
According to the [https://en.wikipedia.org/wiki/World_Health_Organization World Health Organisation] (WHO), based on the largest cohort of COVID-19 patients, about 40% of patients with COVID-19 may have mild disease, where treatment is mostly symptomatic and does not require inpatient care. About 40% of patients have moderate disease that may require inpatient care; 15% of patients will have severe disease that requires oxygen therapy or other inpatient interventions, and about 5% have critical disease that requires the patient to receive mechanical ventilation. However, the evolution of the outbreak in some countries has shown a higher proportion of severe and critical cases and the need to rapidly increase surge capacity to prevent rapid exhaustion of biomedical supplies and staff. In some countries, doubling rates of cases every three days has been observed<ref>WHO-2019-nCoV-HCF_operations-2020, [https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf]</ref> 

South Africa has a high burden of disease, with a high prevalence of [https://en.wikipedia.org/wiki/HIV/AIDS_in_South_Africa HIV and TB]. Although evidence is yet to emerge of the effect of SARS-CoV-2 on a population with these pre-existing conditions, there is reason to proceed with caution<ref>The Conversation 2020, https://theconversation.com/tb-hiv-and-COVID-19-urgent-questions-as-three-epidemics-collide-134554</ref>. There is a potential direct and indirect benefit of ACS to people living with HIV and TB, as well as to general public health and the health system preservation. 

With the travel lockdown in place, and continued transmission, it appears that South Africa is on the cusp between cluster transmission and community transmission according to WHO’s classification, shown in the [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites#Key_clinical_and_infection_control_activities_for_different_transmission_scenarios_.5B3.5D|table below]], indicating that preparation should include temporary hospital facilities and mass critical care.

==== Key clinical and infection control activities for different transmission scenarios <ref>WHO 2020, [https://apps.who.int/iris/handle/10665/331492 https://apps.who.int/iris/handle/10665/331492]</ref> ====
{| class="wikitable"
|-
! !! '''No Case''' !! '''Sporadic Case''' !! '''Clusters of Cases''' !! '''Community Transmission'''
|-
| Faculty Space, Including for Transmission|| Usual Space. Enhanced Screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards). || More patient care areas re-purposed for COVID-19 within the health system, especially for severe cases || Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Staff|| Usual space. Enhanced screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards)||More patient care areas repurposed for COVID-19 within the health system, especially for severe cases||Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Supplies||
*On-hand supplies. Equip wards for COVID-19 treatment.
*Identify essential equipment and supplies, including oxygen.
*Prepare expanded local supply chain
||
*Expanded inventory of supplies with detailed protocols for use.
*Activate expanded local supply chain.
*Prepare national supply chain.
||
*Conservation, adaptation, selected re-use when safe.
*Activate contingency planning and procurement for essential equipment and supplies.
*National supply chain.
*Prepare expanded supply chain at the global level
||
*Activate contingency planning should critical equipment be in short supply.
*Determine allocation of lifesaving resources for HCWs and patients.
*Activate expanded global supply chain
|-
| Standard of Care|| Usual care with enhanced awareness and recognition of immediate needs for first COVID-19 patients|| Usual care and treatment for all patients, including those with COVID-19||Identify context-relevant core services. Shift service delivery platforms. Consider reduction in elective patient encounters, including elective surgical procedures.|| Mass critical care (e.g. open ICU for cohorted patients).
|-
| Care areas expansion|| No requirements for expansion|| Designate 10 beds per suspected COVID-19 case|| Expand COVID-19 patient care areas by a factor of 35 ||Expand COVID-19 patient care areas by a factor of 58
|}

=== Quantification of need ===
At this time there are various parallel initiatives aimed at forecasting the South African epidemic, quantifying the projected need for facilities, and a shortfall in existing capacity. At this time, there is no consensus on this. This section will be updated as further data becomes available.
ACS will prioritise mild to moderately affected COVID-19 patients where basic, targeted medical care will be provided. Should patients’ needs evolve, requiring escalation of care, then the transfer of patients from ACS sites to conventional sites of care will be needed as a matter of course, bringing with it logistical challenges and risks. In the event that the conventional hospital platform is unable to cope, ACS will have pressure to provide care for severe and critical patients, and finally for patients with comorbidity and special requirements, such as paediatrics, persons living with HIV (PLHIV), TB patients and pregnant women. The following pragmatic approach, aligned with the WHO recommended strategic approach, is suggested.
*ACS should preferably be identified with space for expansion.
*The set-up should be done so that levels of care can be upgraded to higher levels of uncomplicated care.
*A secondary upgrade for more diverse package of care may become necessary.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Strategic Approach''' ==
According to WHO, clinical interventions must be put into place immediately and then scaled up according to the epidemiologic profile.
[[File:COVID-19 Resource allocation.png|none|thumb|600px|right|WHO Strategic approach to clinical care]] 
Under this declared state of disaster, the clinical care strategy which cannot be accommodated within existing facilities, can, on a temporary basis be hosted in ACS:
*Within and around existing healthcare facilities, via reconfiguration and/or augmentation.
*In existing non-healthcare buildings suitable for repurposing, such as universities, hotels and conference centres, warehouses, gyms, hostels etc.
*On open fields, including paved parking areas with rapidly constructed, dismountable structures, such as modular tented structures or using rapid modular construction techniques. 

ACS will provide isolation, general (non-acute) care for patients with mild to moderate symptoms and as required, acute care for patients with severe symptoms. Containing confirmed-case patients from general population. Confirmed-case patients can be housed together en masse, while presumptive-case patients must be individually quarantined.
As shown in the WHO Strategic approach to clinical care, the WHO recommends a range of services to meet patient need (''Citation needed''). General (non-acute) care ACS model is designed for minimal acuity patients requiring minimal activities of daily living support (e.g. COVID-positive with minimal symptoms or require <2L of oxygen). Acute care ACS model is designed for higher acuity patients requiring closer monitoring or respiratory support (e.g. COVID-positive with pneumonia or respiratory distress requiring ventilator support). Paediatric patients are to be accommodated in separate wards, where strictly controlled visitation may be allowed. 
As a preliminary estimate, the following ratios of service is proposed:
[[File:COVID Ratios of Service.png|none|thumb|600px|center|COVID Ratios of Service]]

{| class="wikitable"
|-
! '''Case severity, risk factors<ref group="Notes"> Test suspect COVID-19 cases according to diagnostic strategy</ref><ref group="Note"> Known risk factors for severe COVID-19: age over 60 years, hypertension, diabetes, cardiovascular disease, chronic respiratory disease, immunocompromising conditions.</ref>''' !! '''Recommendations'''
|-
|Mild || Patient should be instructed to self-isolate and contact COVID-19 information line for advice on testing
and referral.
|-
|Moderate, with no risk factors ||Test suspected COVID-19 cases according to diagnostic strategy. Isolation/ cohorting in:
* Health facilities, if resources allow;
* Community facilities (e.g. stadiums, gymnasiums, hotels) with access to rapid health advice
(i.e. adjacent COVID-19 designated health post/EMT-type 1, telemedicine)
*Self-isolation at home according to National guidance
|-
| Moderate, with risk factors || Patient should be instructed to self-isolate and call COVID-19 hotline for emergency referral as soon as possible
|-
|Severe || Hospitalization for isolation (or cohorting) and inpatient treatment.
|-
|Critical|| Hospitalization for isolation (or cohorting) and inpatient treatment.
|}

=== Notes and References: ===

<references group = "Note" />
<references />

=== Typology dictates & case studies ===

[[File:NHS Nightingale Hospital London.png|thumb|NHS Nightingale Hospital London <ref name="NHS Nightingale Hospital London">Coronavirus: Building NHS Nightingale Hospital London, 2020 [https://www.bbc.com/news/in-pictures-52092253 https://www.bbc.com/news]</ref>, ]]
To meet the requirements set out in this guidance, prospective “host” sites should be carefully evaluated. The type of “host” site selected will strongly influence or dictate the choice of ACS service model.

No site is likely to meet all requirements and recommendations set out in this document. Adaptations and compromises will be necessary. Services should be provided on site where it is pragmatic to do so, for example where similar services are provided. Outsourcing can also be practical/feasible for some services, such as laboratory services, catering and laundry, provided suitable logistical arrangements can be made.

Some typological responses and service models are set out in precedent examples, shown below. The examples demonstrate that a variety of host settings are workable, provided that the appropriate utility can be contrived.

=== Pragmatic approach ===
Other than in metropolitan areas, co-location of ACS on the premises of, or adjacent to existing healthcare facilities will often be preferable because this is where intensivists and specialist clinical staffing will be available, and support services may be well established. Nevertheless, augmenting capacity at existing facilities should take into account current workloads and capacity to ensure that the COVID-19 surge disrupts normal service provision as little as possible, including continuity of care for patients with chronic conditions and TB and HIV patients. 

*'''[[Infrastructure Guidance for COVID-19/Alternate Care Sites/Case Studies|SARS ACS Precedents and Case Studies can be found here]] '''

=== Notes and References ===
<references />

== '''ACS Infrastructure Planning''' ==

=== '''Establishing a team''' ===
A planning team should be formalised to establish the minimum planning and operational requirements for the ACS and to liaise with the local community. The team should include individuals with expertise in the following areas (ideally with knowledge of healthcare delivery under emergency conditions):
*Disaster response / emergency management coordination,
*Clinical care and staffing,
*Infection Prevention and Control practitioners must be involved in all stages of planning, commissioning, in-use, and decommissioning of the facility
*Facility set-up, operations and management,
*Security,
*Transport (patient, staff),
*Engineering and project management,
*Procurement and coordination of supplies, equipment and pharmaceuticals, and
*Community liaison to ensure that concerns of the adjacent population on understood an addressed.
It is important to ensure compliance with health, safety and building regulations, by ensuring the involvement of relevant local authorities. Stakeholder engagement should be formally documented. Concerns and grievances should be systematically addressed.

=== '''Structural integrity and operational responsibility''' ===

'''Structural modifications:''' ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered. 

'''Competent person:''' All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed. 

'''Asset responsibility:''' Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented. 

'''Integrity and responsibility'''

'''Structural modifications''': ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered.

'''Competent person''': All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed.

'''Asset responsibility''': Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented.

'''Decommissioning''': Decommissioning of the facility shall be assigned to the competent person discussed above. All residual structures upon decommissioning shall comply with the National Building Regulations. Upon decommissioning, removal of equipment shall be the responsibility of the owner. An infection prevention and control practitioner should be engaged in the decommissioning phase to oversee terminal cleaning and disinfection of equipment and premises.

'''Closure''': Once all patients can be safely discharged or transported back to existing facilities for continued care and there are no ongoing healthcare surge capacity needs, the ACS can be closed. Shut down of an ACS will require decommissioning, identification of new homes or storage for equipment, and termination of ongoing contracts or arrangements. Shut down should be expedited so that the facility can quickly be returned to the control of the existing owners and returned to its usual function.

Action checklist items for ACS closure should include, but not be limited to, the following:
*conduct a site walk-through with the facility owner when shutdown activities are completed to ensure that terminal cleaning and disinfection of supplies and premises, removal of equipment and supplies, and other surge closure activities have been completed to the owner’s satisfaction.
*perform medical records storage procedures.

== '''Site Selection''' ==
When selecting a site, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital can be utilised to determine whether the site is suitable for a 100, 1000 or 2000 bed facility, as required. The following indicative minimum site sizes are needed:
*100 Bed ACS/ hospital conversion, requires ± 4 300 m2
*1000 Bed ACS/ hospital conversion, requires ± 17 600 m2
Evaluation should be done by examining plans (if available), satellite images, drone images, scans and by physical inspection (walkabout). A comprehensive photographic survey should be undertaken and retained for record purposes on the site inspection. This will serve as an audit record and may assist in returning the site to its original function on ACS decommissioning and closure. When scrutinising documents and conducting site inspections to confirm the suitability of a site to host an ACS, the following criteria should be taken into account.
=== Criteria ===
*Affordability (costs, including operational costs known and budget identified),
*Sufficient physical space and capacity to house the immediate need, with the potential to accommodate physical space requirements. For example, open site should not be sloping,
*Legal rights and encumbrances, including renewal opportunity,
*Good access to highway and main roads,
*Well secured perimeter and limited controlled access points,
*Proximity to other hospitals and care sites,
*Accessibility for key staff and public transport,
*Good vehicular access around the site to set up temporary equipment such as back-up generators,
*Free from clear and present danger,
*Outside attenuation zones, floodplains,
*Outside high wind zones,
*Structure in good repair,
*Effective onsite facilities management team who understand how systems work,
*Potential for expansion, if required,
*Access to sufficient capacity for
**potable water,
**adequate sewage,
**telephone,
**internet access with sufficient bandwidth,
**electricity,
*A zone for cleaning, disinfection, and decontamination of equipment at least 15 metres away from occupied areas with access to water, a hard impervious surface and drying areas in the sun, with runoff discharge into the sewer and not into marine ecosystems or the environment. Include area for cleaning and storage of cleaning equipment.
*Likelihood of acceptance of hosting an ACS by the adjacent and local community

=== Desirable ===
*Durable, cleanable surfaces,
*Large open spaces that can be converted to accommodate temporary structures,
*Good ventilation,
*On-site kitchen and laundry,
*Housekeeping staff (chemical and equipment storage, lockers, rest facility, administration office),
*Space conducive for staff respite area and locker rooms,
*Amenities with universal access,
*Fire protection safety and equipment,
*Elevator access for patients if the building has more than one floor,
*Capacity for expansion, and
*Accessible to at least two roadways to provide continued access in the event that one roadway becomes blocked on inaccessible.

== '''Infection Prevention and Control''' ==
General guidance for COVID-19 [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|Infection Prevention and Control]] can be accessed [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|here]] 

Infection prevention and control in the context of COVID-19 should respond to transmission routes of primary concern for the pathogen of interest (droplet and contact transmission, and management of risk waste) as well as infection risk of a general nature (water and sewerage, airborne transmission – under high TB/HIV burden, and general waste).
In addition to satisfying [https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html standard precautions for all patient care], transmission-based precautions should focus on three pillars: exposure reduction by spatial configuration, operational strategies, and personal protection.
=== Transmission-based precautions ===
'''Droplet and contact spread''': Transmission of SARS-CoV-2 virus occurs via droplet and contact spread. The virus has been shown to persist on surfaces for extended periods of time and is known to be efficient at infecting people. 

'''Medical waste and linen:''' As SARS-CoV-02 is carried in body fluids and faecal matter, disposal of contaminated items (tissues) and cleaning regimes (spaces, garments, linen) should be accommodated carefully in the workflow design and infrastructure provision. A site-specific waste management plan should be formulated in accordance with a site-specific waste management plan with reference to SANS 10248. 

'''Airborne transmission:''' Under exceptional circumstances, the risk of airborne transmission arises for SARS-CoV-2, as detailed below.
{| class="wikitable"
|-
!Airborne Transmission Risk Factors
|-
|
As SARS-CoV-2 is not considered airborne, respiratory protection against airborne transmission is not considered necessary, except where aerosolisation of particles may be a risk.
According to the CDC
*tracheal intubation,
*non-invasive ventilation,
*tracheotomy,
*cardiopulmonary resuscitation, or
*manual ventilation before intubation and bronchoscopy.
According to doctors in the field also when performing
*COVID-19 diagnostic sampling as patients can be induced to cough and sneeze.
*Suspected or confirmed comorbidity of TB is not an additional risk where correct COVID-19 PPE is applied.

|}
South Africa has a high prevalence of TB and HIV, and therefore, although the risk of COVID-19 transmission via the airborne route is not paramount, there is a high likelihood that undiagnosed TB infectious patients may present at the ACS for treatment. TB triage may be challenging in the ACS as there are symptoms in common (coughing) with COVID-19. This country-specific risk is taken into account in this guidance

=== Additional precautions ===
'''Water and sewerage contamination:''' The International Water Association [[Infrastructure Guidance for COVID-19/Alternate Care Sites/COVID-19 A Water Professionals Perspective|concluded]] that water and sewerage contamination is not considered to be a key risk factor for COVID-19. The panel expressed concern for “how waste and specifically wastewater (medical) would be handled by places (e.g., hostels, hotels) that are used to serve as interim COVID-19 quarantine or testing facilities or accommodation ([ACS]. These are places other than hospitals that are used in the interim for such purposes and do not usually handle wastewater from medical settings. Such facilities should be monitored carefully.” 

== '''Spatial strategies for infection prevention and control''' ==

=== Restricted access and zone control ===
The site will be arranged to establish clear zoning, with a clear restricted zone protocol and access protection. Zones should be deemed to be "contaminated" or "uncontaminated" with clear transition areas between them.

; Contaminated zones
: (also known as "dirty areas") are areas occupied by COVID-19 infected persons, PUIs, equipment, materials and supplies which have come into contact with such persons without yet undergoing a decontamination procedure. These areas will include patient ward areas and ablutions, patient admissions (including ambulance drop-off) and the associated clinical areas. Staff rest and dining facilities should be outside the contaminated zone. Limited stock for immediate use should be kept in the contaminated zone. Layout designs should consolidate contaminated zones as far as reasonable, and avoid uncontaminated zones as islands in contaminated zones.

; Uncontaminated zones
: (also known as "clean areas") are areas not generally occupied by PUIs or confirmed COVID-19 infected persons. Equipment, materials and supplies in these areas have not yet come into contact with contaminated zones or have undergone a decontamination procedure. These will include clinical management planning rooms, stock rooms, bulk stores, pharmacy, laboratory areas, kitchen and laundry.

; Transition zones
: (also known as intermediate zone) are the spaces through which transfer of people and goods from uncontaminated to decontaminated zones, and vice versa, occur. Materials from the contaminated zone should be decontaminated or contained in the transition zone. The transfer of goods and persons should be highly ritualised and, as far as possible, traffic across transition zones should be minimised. Transition areas should be strategically located to serve this function. Separation of in-going and out-going transfer of goods and persons is preferable. Transition areas include ambulance, trolley decontamination, CSSD, laundry and waste bagging areas, patient locker area and staff change areas with spaces for donning and doffing of PPE.

=== Site layout and master-planning ===
Spatial configuration and layout can ensure unnecessary cross-over of function is avoided. This entails the systematic separation of functions and the managed transition between activities to facilitate consistency of care, an orderly, efficient work environment, less waste and reduced risk for improved outcomes. To achieve this, functional relationships should first be considered at the site level before being considered at the building level. 

<gallery mode=packed heights=300px style="text-align:left">
Layout for a SARS facility, clustering functions with minimised cross-over.png|center|thumb|Layout for a SARS facility, clustering functions with minimised cross-over <ref name="Layout1">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Layout_for_a_Patient_cohorting_strategy.png|center|thumb|Layout for a Patient cohorting strategy <ref name="Layout3">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Tygerberg Hospital virus triage unit site layout.png|center|thumb|Tygerberg Hospital virus triage unit site layout <ref name="Western Cape Provincial Government, 2020a">Western Cape Provincial Government, 2020 a</ref>
</gallery>

The WHO's Clustering Layout <ref name="Layout1"/> and Tygerberg Hospital virus triage unit<ref name="Western Cape Provincial Government, 2020a"/> show worked examples of building and site layouts, which are configured with these principles, respectively. '''Cohorting''' is defined as clustering patients with similar or compatible clinical needs together for risk reduction, acuity, efficiency and quality management, as illustrated in WHO's Cohorting Layout <ref name="Layout3"/>

=== Workflow ===
Within individual functional zones, the workflow activities can be arranged to proceed from clean procedures to contaminated procedures. In the example below, the staff arrival, PPE donning, doffing and patient flows are worked to have controlled interaction and minimised cross-over

<gallery mode=packed heights=400px >
ACS HCW Flow.png |ACS Health Care Worker Flow
COVID-19 Workflow in small unit.png |COVID-19 Workflow in Small Testing Unit <ref name="Western Cape Provincial Government, 2020b>Western Cape Provincial Government, 2020 b</ref>
COVID-19 Workflow in large unit.png |COVID-19 Workflow in Large Testing Unit <ref name="Western Cape Provincial Government, 2020b"/>
</gallery>

As far as possible, a single direction flow of clean to dirty is recommended for all processes: support services, supply and waste.
The Small ACS unit workflow diagram<ref name="Western Cape Provincial Government, 2020b"/> illustrates the recommended separation of access and exit, separate waiting seats, for persons who may be COVID-19 infected. Separate spaces are provided for donning and doffing PPE. Staff change areas are provided.

In the Large ACS unit workflow diagram <ref name="Western Cape Provincial Government, 2020b"/>, there is a clear separation between staff areas and patient areas. Waiting seats are set far apart to reduce transmission risk. Staff change rooms are provided near the point of entry to the facility for staff to change from street clothes into medical work clothes. To prevent work clothes worn inside the facility from contaminating street clothes, these are kept in separate lockers. A step-over barrier from dirty to clean sides of the change room is helpful to enforce a mind-set of avoiding cross-contamination. Bins for contaminated garments are to be provided in change rooms. Shower facilities are to be provided for staff.

== '''Operational Strategies''' ==
=== Cleaning, disinfection and decontamination ===
Surface and substrate specification, and detailing of all areas should, as far as possible, allow for frequent:
*Cleaning with detergent and water.
*Disinfection with 75% alcohol solution (metal surfaces).
*[https://en.wikipedia.org/wiki/Sodium_hypochlorite Sodium hypochlorite] (1,000 ppm)/ Household bleach.
*Disinfectants listed on the EPA List N<ref>The United States Environmental Protection Agency, [https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 List N: Disinfectants for Use Against SARS-CoV-2 (Last Visited 2020) ]</ref> (for non-critical environmental cleaning).
*High-intensity ultraviolet surface disinfection (UV-C).
*Decontamination and sterilisation of clinical equipment.

=== Goods and waste management ===
Remove any unnecessary furniture, equipment and paraphernalia from all patient care and clinical areas. Provide a clear, secure space for waste management. Any potentially infectious waste materials generated at the ACS should be considered and treated as medical waste (health care risk waste). The applicable legislation is:
*[https://www.gov.za/sites/default/files/gcis_document/201409/35405gen452.pdf The National and Provincial Health Care Risk Waste Management Regulations].
*[https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf National Department of Health COVID-19 Environmental Health Guidelines.]<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>
Waste disposal bins should be positioned near the exit inside each patient rooms or wards to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another patient in the same room.

=== Materials and finishes ===
Floor materials must be:
*Level,
*Free of dust and oil,
*Impervious and smooth,
*Slip-resistant in wet areas (e.g. patient ablutions).
Smooth, cement screed floors are acceptable. Where hosting facilities have carpeted areas, a risk assessment of factors such as durability, hygiene and decontamination needs to be conducted. In cases where the acceptance of carpeted flooring is contradicted (but other factors make it a compelling option), temporary floor finishes or covering can be investigated.

== '''Personal protection''' ==
=== Hand sanitation ===
Where wash-hand basins are not provided, clinical wash-hand basins should be installed, at the minimum rate of provision of one wash-hand basin per 5 beds. Clinical wash-hand basins (see figure below) have a variety of features not present in standard wash-hand basins, which are preferable for infection prevention and control. Where standard wash-hand basins are provided, an upgrade is not necessary. In all cases, there should be no surfaces and no clutter, equipment or supplies in the vicinity of wash-hand basins, including surgical gloves.
<gallery mode=packed heights=400px>
Clinical hand wash basin.png|Handwash Basin <ref>de Jager 2020</ref>
Portable Wash-hand Basin.png|Portable wash hand basins can be provided in ACS <ref name="BDPa">BDP 2020, NHS nightingale instruction manual, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf</ref>
</gallery>

Where wash-hand basins are not available, portable units can be used, as shown above<ref name="BDPa"/>. Mounted brackets for hand sanitisers are to be provided for every two beds, preferably mounted near the foot rather than the head of the bed and at all common touch points such as entry points at ablution facilities, linen room, sluice, storerooms, medicine rooms/cupboards, near refrigerators, telephones, light switches, at entry/exit doors, etc.

=== Personal protective equipment ===
Donning and doffing points for personal protective equipment, and convenient, safe disposal of consumables to be placed at critical key points when entering patient areas.
----

== '''General transmission mitigation''' ==
=== Water and sanitation ===
To comply with National Building Regulations; Hazardous Biological Agents Regulations and National Department of Health COVID-19 Environmental Health Guidelines<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>.

=== Droplet aerosolisation ===
When designating areas for procedures during which aerosolization and airborne transmission risk is high, the building ventilation must be carefully considered to take into account downstream risks. In particular, consider to where potentially contaminated air, arising from aerosol-generating procedures, is exhausted. In general, air exhausted directly to the outside is diluted and considered safe, unless there are openings to occupied spaces near the exhaust air outlet. 

In the event that potentially occupied spaces will receive partially diluted or undiluted contaminated air, or where this is indeterminate, the aerosolising activity should be designated to an alternate area. In the event that an alternative is not available, some treatment regime (air filtration or air disinfection) is necessary. 

In most naturally ventilated settings, the airflow direction between zones may fluctuate according to the wind direction. Such high-risk spaces should not be adjacent to spaces with high susceptibility rates, such as PUI areas and uncontaminated areas. Contaminated areas should not be directly adjacent to clean areas unless mechanically ventilated. 
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|Guidance on COVID-19 building ventilation design is provided here]].

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Health, Safety and Well-being''' ==
In addition to the infection prevention and control measures discussed above, the following should be provided for health, safety and well-being.
=== General provisions ===
*Minimised and controlled entry and exit points, with suitable control.
*Clearly identified accessible and marked routes for patients, staff, goods and waste.
*Clear designation of restricted zones.
=== Site level provisions ===
*Safe staff parking and arrival of staff via planned and public transport.
*Clearly demarcated parking for people with disabilities.
*Arrival and departure point for patients via public transport, passenger vehicles, and emergency service.
*Limited safe patient parking.
*Supply of goods and removal of waste.

=== Within and between buildings ===
*Entrances with a clear opening width (CoW) of at least 900mm.
*Routes with a minimum width of 2 000mm free of hazards, for example, rubbish bins.
*All clinical, patient and support areas to be accessible by trolley.
'''Ramps''' should be of stable construction, capable of sustaining a mass of 300kg. They should incorporate side lips and the surface should be slip-resistant. Gradients should be as gentle as the circumstances allow. (Recommended maximum 1:20). 
'''Small changes in floor levels''' are not desirable, but where these exist are to be clearly marked with reflective paint/ tape, and lit at night
Elevators between different floors, where patients need access (The recommended minimum lift size for patient trolley/stretcher movement is 1 400mm × 2 400mm, however, this may not be possible). 
'''Pathways''' to be lit at night, where used at night. 
'''Staircases''' must be well-lit at night with non-slip surfaces and secure balustrades. 
'''Doors''', Double doors and automated or push-operated doors to all clinical areas are to be preferred, where these are newly installed or able to be retrofitted. Door closers are to be disabled, where not necessary to reduce touch surfaces. Hand sanitisers to be provided at where high touch common surfaces occur (e.g. wall-mounted at doorways).

=== Signage ===
The appropriate level of information to facilitate legibility, orientation and wayfinding. Minimum standards, signage to be:
*Clearly visible, simple font, font size, contrasting colours, placed in the field of vision
*Washable
*Comprehensive safety signage - fire signage (exits, equipment etc.)
*Restricted areas clearly marked
*Identification signage - each patient space to be allocated a unique number and a whiteboard or perspex sheet for writing the patient’s name
Signs should be posted immediately outside of patient rooms indicating appropriate IPC precautions and required personal protective equipment (PPE).
Signage of a temporary nature can be provided on laminated white A4 sheets attached eye-level. The text should be black sans-serif (for instance Arial) text at least 40point size and centrally positioned on the sheet. Detailed guidance on signage is provided in IUSS Inclusive environments.
=== Safety and security ===
Upon identification of the ACS host site, a team should be convened to conduct a multidisciplinary safety and security analysis. These critical team members need to form the working committee responsible for undertaking the detailed assessment of the existing facility’s security. They should analyse data about the security system’s condition and review existing security concerns or issues that are reasonably likely to become concerns in the near future. The figure below represents a five-zone approach to security, which is a recommended, systematic approach to security.
[[File:Zonal approach to security.png|center|600px|thumb|IUSS Security- Zonal Approach to Security <ref name="IUSS Security">IUSS Hospital design principles - Security [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file]</ref>]]
The security strategy should take into account that whilst clinical services and some logistical and support services will be required 24 hours a day, seven days per week, some support services, logistics services and auxiliary services may only be operational for the minimum periods required to meet demand. These functional elements should be capable of being secured, for example over weekends and at night, as the case may be.
Detailed guidance is available in [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file IUSS Hospital design principles - Security] <ref name="IUSS Security"/>

=== Comfort and dignity ===
Supplemental heating: Patient health and comfort are dependent on, amongst others, maintaining body temperature. The ACS structural technology must be selected to achieve the general indoor environment conditions discussed in a subsequent section for all clinical and occupied areas. As we are moving into South African winter supplemental heating may be required, especially in the evenings, in order to avoid hypothermia. Use of fans, bar, radiator or gas heaters should be prohibited. Unless clinical areas can be maintained above 18 degrees centigrade, patients should each have an infrared heater available, in addition to blankets. Personal/ donated blankets can be considered if they are laundered first and could be destroyed upon discharge.
Mobile screens should be available to provide privacy where necessary (e.g. during consultations or procedures).
<gallery mode = packed heights = 400px>
Bed_Isolator_-Vietnam.png|thumb|Flexible Barrier Isolator<ref>WHO. (2020), Severe Acute Respiratory Infections Treatment Centre. Geneva, Switzerland : WHO- World Health Organization</ref>
ACS Cohort beds.png|ACS Cohort beds.png|thumb|Excel Centre London 04-2020 <ref>Architects' Journal 2020, [https://www.architectsjournal.co.uk/news/nhs-nightingale-bdp-on-the-first-nine-days-converting-the-excel-centre/10046749.article https://www.architectsjournal.co.uk/news]</ref>
</gallery>
Some solutions which address patient privacy and dignity are depicted above.

=== Notes ===
<references/>

== '''Schedule of Accommodation''' ==
Based on clinical needs of the ACS, a schedule of accommodation can be crafted capturing the clinical, clinical, logistical, support and auxiliary services associated with the render of care. When deriving a schedule of accommodation, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital tool can be used. Functions to be accommodated are: 
'''Clinical services''': Triage, rapid assessment of persons entering the facility, to expeditiously identify and render the appropriate service. Admissions and registration. Inpatient accommodation is to be organised according to cohorting principles, discussed above. Testing and diagnostics, including laboratories and x-ray. Safe storage and dispensing of drugs to patients.Offices for clinical administration and clinical planning meeting rooms in the clean zone are needed. 
'''Logistical services:''' Logistical services will entail management of flows of people, goods, services and information to and from the site, as well as within the site. It includes security and communication arrangements. Staff entry, preparations to transition from outside to clinical work environment, including pause areas for relief. Emergency services, visitors. Goods, supplies and storage and waste removal and/ or treatment.
Support services key to the provision of clinical services should be separated so that the risks associated with that particular activity can be managed. 
'''Support services are:'''
*Laboratory services
*Catering
*Laundry
*Environmental cleaning and housekeeping
*CSSD
*Maintenance and cleaning of surrounds, eg. waste areas
*Porters/”runners”, stretchers/wheelchairs
*Mortuary
* Security
Support services can be provided off-site, in which case, safe, secure and efficient transfer and logistical arrangements should be designed. 
'''Auxiliary services:''' Auxiliary services are services which may be provided on or near the ACS site, but which are not directly related to core clinical care. This included overnight accommodation for staff who may not wish to return home to avoid exposing their families, or who need rest between shifts, or for discharged patients awaiting transport home, volunteers who have recovered from SARS-CoV-2.
Limited psychosocial services and allied health services may also be provided on or near ACS for example by approved partners.
Examples of schedules of accommodation for patient and support spaces for a protective isolation ward is available [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedule for COVID-19 Isolation Wards|here]] and mild to severe cases [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedules for COVID-19 Wards for Mild to Severe Cases|here]].

== '''Clinical Services''' ==
=== Triage ===
Confirmed COVID-19 cases and PUIs who are referred from a testing facility or a higher level of care, will enter the facility in a triage area to receive vital screening and initial assessment. They will be registered and admitted to inpatient care. They will be assigned a "ward" or section of the facility - based on disease status and acuity. These are Protective Isolation, the Mild & Moderate ward, or the Critical & Severe wards. Patients should be clustered according to gender. As far as practicable, ablutions for each gender, isolation patients, paediatrics and staff shall be separately provided. Paediatrics patients, if admitted, are to be assigned a dedicated section.
As patients recover or deteriorate, they may be relocated to the appropriate section/ ward.
Once the patient has sufficiently recovered and a negative test result is received they will be appropriately decontaminated and discharged, collecting medication from the dispensary on exit. Patient movement between various sections of the ACS will be restricted as far as possible, with mobile radiology units, in-ward medication dispensing and in-ward food service.

=== Inpatient ACS accommodation ===
Separate spaces for:
*suspected, unconfirmed cases, under observation (PUIs), to be accommodated in isolation facilities (separate rooms, if possible);
*patients with confirmed COVID-19 with mild to moderate disease, not requiring dedicated oxygen therapy;
*patients who require dedicated oxygen therapy;
*patients requiring mechanical ventilation; and
*recovered/ confirmed negative.
==== Protective Isolation Facilities ====
Suspected, unconfirmed cases, under observation – persons under investigation (PUIs) to be accommodated in protective isolation facilities (separate positive-pressure rooms, if possible). PUI are restricted to their rooms. All food and laundry services will be brought to the PUI rooms to reduce interaction and potential contamination. All waste will be collected by facility staff and taken to waste handling areas. Infection prevention and control measures are put in place for the handling of used food utensil and laundry as well as waste collection. PUI areas will have restricted access, including for staff serving other inpatient sections, for confirmed cases.

==== Inpatients accommodation for confirmed COVID-19 ====

Inpatient facilities confirmed positive COVID-19 can be accommodated in large shared ‘wards’ with partitioning between patients. Partitioning between patients is optional. Partitioning is preferable to curtains found in conventional hospitals, as they are more conducive to daily cleaning. If curtains are used, antimicrobial treated fabrics with biocide used to treat the curtains has been tested to international standard EN 14476 and shown to be effective against H1N1 Influenza A Virus (Swine Flu), >99.999% kill rate in 5 minutes and measles morbillivirus, >99.99% kill rate in 5 minutes are preferred. If only separate rooms are available, patient monitoring and surveillance will need to be accommodated. This phase of treatment has a lower area/space requirement compared with PUIs, as cross-infection between patients is less of a concern. Shared ablution facilities are acceptable. It is recommended that, at least, two general accommodation ward areas be provided. 

a) Mild and moderate patients, and 
b) Serious and critical patients. 

The room must have openable windows for natural ventilation if a dedicated positive pressure ventilation system is not available. Ducted ventilation systems shall not be shared between PUI areas and confirmed COVID-19 patient areas. 
[[File:COVID-19 ACS - protective isolation – bed layout.png|thumb|center|800px|ACS - protective isolation – bed layout]]
[[File:COVID-19 ACS – mild-moderate patient bed layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient bed layout]]
[[File:COVID-19 ACS – mild-moderate patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient shared ward layout]]
[[File:COVID-19 ACS – severe-critical patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – severe-critical patient shared ward layout]]

Examples above show bed layout with bed spacing for protective isolation, a mild/moderate patient and a mild/moderate patient shared ward and for a severe/critical patient

=== Patient services ===
Patients in ACS will not generally be ambulatory and will be confined to their room, or cubicle in a bed. In general, domestic beds or hospitality industry (hotel) beds are not suitable for patient care. These should only be used where a hospital-grade bed cannot be sourced, as hospital beds are designed for ease of cleaning and decontamination (for infection prevention and control) and with patient and ergonomics, safety and comfort taken into account (they prevent back injury for nursing staff and can help to prevent bedsores). The higher the specification of bed, the more suitable it is for the higher levels of care. Lockers for patients personal belongings should be provided in the uncontaminated zone (in which case bedside lockers will not be necessary), and it is preferable (where bedside lockers are not provided) for overbed tables to be provided, per bed, if possible. 
The following beds are suitable:
*Repaired and refurbished beds from condemned hospital stocks.
*South African National Standard, SANS 521:2013 Edition 3.5, on Hospital beds and cots ISBN 978-0-626-28830-3.
*Beds listed on the National Treasury (See [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Hospital Bed Specification|specification]]).
The table below details the minimum services required at each patient bed. Details on these services are discussed in a subsequent section of the document.

{| class="wikitable"
|-
! Service/ Capacity!!Triage!!Isolation !!Mild – moderate inpatient!!Severe case wards!!Critical case wards
|-
| Power – 16A 230V Single socket outlet||As needed ||1 per bed||1 per bed||3 per bed||6 per bed
|-
| UPS Power – 16A 230V Single socket outlet ||As needed||1 per bed||1 per bed||1 per bed||2 per bed
|-
| Medical Air<ref group="Note">Mobile units recommended for intermittent use. 3 per 20 beds</ref><ref group="Note">There are some ventilators which have built-in compressors allowing them to function without Medical Air. This is however, not the norm. With Ventilators probably being the most difficult medical device to obtain at present, it would be prudent to rather allow for Medical Air at each bed.</ref> (LP)400kPa||No||Yes||No||Yes||Yes
|-
| Medical O2 -400kPa||Portable/shared||Portable/shared||No||One||Two
|-
| Vacuum-40kPa||No||Portable/shared||Portable/shared||Yes||Yes
|-
| Equipment rail||||||||Yes||Yes
|-
| Upper room UVGI||Optional||Optional||||||Optional
|-
| Examination light||No||No||Yes||Yes||Yes
|-
| Room Ventilation rate||60 L/s per person||10 L/s per person||10 L/s per person||10 L/s per person||12 ACH
|}
'''Notes: '''
<references group="Note" />

Two additional 16A 230V single socket outlets, one two-pin outlet and a worktop should be provided for every 32 beds (or part thereof), for:
*Electrocardiograph (ECG): Could be omitted if monitors have a full 12 lead ECG function.
*Blood gas analyser: Could be omitted if a Lab Services are available.
*Staff cellphone charging.

Example of healthcare technology to be provided for critical care patients is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]. Severe patients may be provided continuous positive airway pressure (CPAP). Emergency trolleys (“crash carts”) are to be provided in patient areas with convenient access to patient beds, out of the passage of corridors and is moved to the patient when needed. 1 crash cart for every 16 patients (or part thereof, with at least one dedicated for PUIs. An example of provisions for a crash cart is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]
==== Patient ablutions ====
[[SARS-CoV-2 is found in faecal matter]], so careful management of patient body fluids is crucial and convenient, practical support for frequent cleaning of ablutions especially shared ablutions is necessary. Dedicated ablutions (toilets and showers) are to be provided for patient use. Toilets and showers should be in separate rooms.
Hand washbasins and or/ hand sanitiser should be provided both inside and outside the toilet room so that patients can wash their hands on the way in and on the way out of the room.
*1 toilet for every 8 persons.
*1 shower for every 8 persons.
*1 disabled ablution for every 8 regular ablutions (or part thereof).
*1 disabled shower for every 8 persons (or part thereof).

Critical and severe patients may be sedated and have a reduced need to access ablutions, ablution facilities proximity and provision can take this factor into account. Showers and wash hand basins should have hot and cold running water. Where possible ablution facilities must have openable windows for natural ventilation, if not possible the bathroom extraction and room ventilation system must be reviewed before admitting patient '''(see [[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|ventilation]]).'''

Portable toilets and showers may be used, provided that suitable hand wash facilities are provided. These will need to be suitably located, preferably in decentralised clusters, so that patients can easily access them without needing to walk very far. Ablutions should be located and designed in such a way as to provide visual and acoustic privacy, dignity and avoid disturbance of other nearby patients when accessing, using or cleaning the ablutions. Separate ablutions are to be provided for PUIs and confirmed patients.

====Makeshift sluice areas ====
In conventional hospital settings, sluice rooms are provided for cleaning and sanitation of soiled equipment, such as bedpans. In a temporary setting, such as an ACS, the establishment of a temporary sluice room may not be practicable, and there may not be facilities for emptying buckets, rinsing equipment etc.. The following is suggested:
Allocate a toilet, hand wash basin, not in splash range and restrict access to it for draining buckets and install a macerator for disposal of disposable bedpans. Electrical, water and waste supply points required as per supplier specification.
==== Dedicated patient treatment areas ====
The following dedicated, private spaces per ward for clinical procedures are recommended:
*Counselling and consulting room (can be shared), as shown in the figure below
[[File:Consulting room example layout.png|400px|thumb|center|Consulting room example layout]]
*Minor procedures room, as per the example provided in the figure below 
[[File:Treatment-minor procedures room example layout.png|400px|thumb|center|Treatment / minor procedures room example layout]]

== '''Logistical Services''' ==
=== Communications ===
Electronic communication should be facilitated in all zones of the ACS by the provision of device charging stations, and wifi.
=== Visitors entry point ===
Visitors are strongly discouraged from entering the ACS.
*In paediatric wards, one parent may be accommodated to visit a patient. In such cases, direct access for the visitor should be provided so that the visitor does not need to pass through the general patient area. Appropriate PPE must be donned before entering the patient area and hand washing/sanitising must be done when exiting the area.
*Non-patients who are accompanying suspected patients to the facility for testing or admission must be accommodated in a well-ventilated, spacious waiting area. Signage in such waiting areas must inform visitors about symptoms, hand hygiene and PPE.
*Hand washing/sanitizing facilities should be provided.

=== Staff areas ===
==== Staff change rooms ====
A minimum of 9m² or 4m² for a single person, increasing by one m² for each additional person is required. The clean (street side) and dirty (contaminated facility side) of the change room should be separated by a step-over barrier.

==== Staff rest areas ====
Staff rest areas within the main facility should be provided with access to kitchenette facilities and staff ablutions.
=== '''Staff auxiliary services''' ===
'''Staff on-call:'''Since staff may be required to work long hours or could be required to be on-call, shared, overnight sleeping facilities can be provided for staff on duty, outside the contaminated area, but in close proximity on the patient areas. An example is set out in the diagram below.
[[File:Example of on-call sleeping area for staff.png|center|600px|thumb|Example of overnight sleeping area for staff]]

'''Staff accommodation:''' It is advisable to provide some staff accommodation for off-duty staff who may not have suitable alternatives, for example homes too far away, transport limitations or the requirement not to expose family members to risk. This should be provided in the vicinity of the ACS, but in a physically separated zone. This amenity can be outsourced.

== '''Support Services''' ==
=== Workflow principle ===
[[File:Linen processing cycle.png|none|thumb|Linen processing cycle <ref>IUSS 2014 [https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department]</ref>]]
Progressive workflow from “dirty” (that is contaminated) to “clean” linen is advisable to reduce the risk of exposure to contaminated materials. The workflow diagram below, showing the progression from the dirty linen receiving area, to the cleaning process, to decontamination and drying, and finally sorting and packing, and storage, illustrates this principle.
=== Laboratory ===
[[File:Example of modular laboratory.png|right|thumb|Example of modular laboratory]]
The WHO recommends the following laboratory diagnostic equipment be accommodated:<ref>WHO 2020, [https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items]</ref>.
<nowiki>• Lab screening test kit
• Lab confirmation test kit
• RT-PCR kit
• Extraction kit
• Cartridges for RT-PCR automatic systems
• Swab and Viral transport medium
</nowiki>
Additional accommodation requirements are:
# Reception counter- receiving specimens
# Testing with perspex/ glass screen
# Receiving/Data capture
# Specimen holding
# Toilet - staff
# Blood storage fridge
Can be provided as a modular laboratory unit as shown in the diagram.
=== Pharmacy ===
The purpose of the pharmacy is to provide medicines needed for inpatient treatment and care.
All medical supplies should be stored in a secure, climate-controlled area in close proximity to the patient treatment area. The pharmacy must have dry, lockable, climate-controlled storage of medications. Most pharmaceuticals are labelled with storage temperatures. The pharmacy should have adequate ventilation through an openable window to prevent humidity from building up in the room. Air-conditioning or mechanical ventilation can be provided, if necessary.

Dispensing areas must be well lit. Worktop in space for stock records and administration. Dispensing counters to have perspex or glass screens to serveries. Social distancing implemented at counter, between pharmacists/assistants and between chairs in waiting area.

Can be provided in a mobile unit.

=== Radiology ===
The purpose of radiology services is to provide chest X-Ray services for COVID-19 diagnostics. In general, CT scans, bucky rooms etc. associated with some radiology equipment require specialised infrastructure and therefore is not suitable for ACS. Radiology services can be provided as a mobile floor standing unit, or containerised unit. Alternative technologies such as Lodox and hand-held ultrasound devices are being investigated as potential options and could be confirmed as suitable for use in due course.
=== Laundry services ===
All dirty linen should be handled for bagging or binning inside the patient room/cohort area. The clean linen stock should be stored conveniently close to clinical areas, in a dedicated clean area in the uncontaminated zone. Used linen should be stored in a designated, safe, lockable holding area while awaiting collection. Interim storage areas for soiled linen at the wards is allowable; this may be in dirty linen/ utility room.
Any clean linen for PUI areas should be handled in spaces physically separate from dirty linen of confirmed patient areas. It may be necessary to completely separate PUI and confirmed patient linen streams. Soiled linen and clean linen bags and bins should be dedicated and not mixed.
Full laundry cleaning and drying services may be provided on-site or outsourced. If laundry cleaning and drying services were already rendered on or for the host site before it is repurposed as an ACS, then a suitability and risk assessment should be conducted to ensure that the volumes of laundry generated and infection prevention and control measures are conducive and modifications made as necessary. A new full laundry service may take time and resources to establish, and in general, will not be established at a host site as a temporary solution. Where the site and circumstances advocate for the design of a new laundry or the upgrade of an existing laundry, the IUSS Laundry Services for Hospitals should be applied.
==== Siting and model selection considerations ====
When an existing laundry is being assessed for use or a new one is being planned the following considerations apply:
* Water and power capacity.
* Ease of access to the ACS’s main corridors and internal transport routes.
* The noise factor of the facility and its impact on nearby patient care departments.
For outsourced departments:
* Delivery areas to allow sufficient space to ensure that vehicles can manoeuvre and park easily at the reception and dispatch bays.
* Access to the ACS service roads and public roads.
==== Functional requirements ====
The most basic equipment needed in a laundry includes washing machines, tumble dryers and ironing machines. Equipment requiring steam is not recommended for a temporary facility. The sizing of the laundry, equipment and engineering services can be modified based on the principles provided in the IUSS Laundry and linen.
=== Catering services ===
Kitchenettes, that is, areas for tea, coffee and snacks, mainly for staff, in staff pause areas are discussed elsewhere in this document.
Catering services (for staff and patients) may be provided on- or off-site. If the ACS is to be established with easy access to a suitable, existing, functional kitchen service (e.g. hotel, military or hospital catering) which can meet the additional demand of the ACS, then this should be used. If there is no suitable facility, catering should be outsourced via a suitable off-site supplier. Only in the event that no feasible or suitable, existing facility or local supplier is available, should a new catering service be established at the ACS. Detailed guidance for the sizing, design and layout of catering services can be found in the IUSS Catering Services for Hospitals.
The kitchen (for on-site catering) or preparation area (for off-site catering) should be located with easy access to the point of delivery and storage of food. Adequate food and equipment storage space must be provided.
It is recommended that patient and staff meals, where provided, be supplied in disposable, containers, suitable for incineration, and that these are disposed of as risk waste immediately after use.
Where off-site catering is used, a suitable area for receiving should be provided. Space will be required for sorting meals for distribution and collecting and storing dirty dishes, washing dirty dishes, if necessary, and disposing of left-over food and disposable containers and utensils. The size of the areas required for this will depend on the number of meals delivered.

=== CSSD ===
The primary function of a Central Sterile Supply Department (CSSD) is to provide an efficient, economic, continuous and quality supply of disinfected and sterilised items, when needed, to all patient-care service points in the ACS, and to receive returned contaminated items for cleaning.
CSSD with limited sterilisation capacity (autoclave) but sufficient disinfection capacity (instrument washing). The layout requires a designated clean and dirty areas with a hard barrier between to avoid cross-over of staff and equipment. Work is unidirectional - flows from dirty – to clean - to sterile areas.
This yields three distinct zones:
1. Receiving and cleaning with pass-through windows
# Dirty receiving with Perspex or glass partitioning
# Dirty utility
# Decontamination and cleaning/wash area with throughput instrument washing
# Trolley wash/Park – external
2. Inspection, assembly and packaging with pass-through windows
# A tabletop autoclave
# Instrument washer
# Clean Packing area
3. Sterile processing, storage and distribution. (Separate issuing area from receiving area) with pass-through windows
# Store -linen and consumables
# Sterile pack store
# Issue - Collection hatch with Perspex or glass partitioning
Must also have a secure, separate receiving area for consumables receiving and storage.
An example of a CSSD unit is shown in Figure 21.T

[[File:An example of a small CSSD facility.png|600px|thumb|none|An example of a small CSSD facility<ref>IUSS 2014, https://www.iussonline.co.za/norms-standards/support-services/24-central-sterile-service-department</ref>]]

To be understood: Quality of services, eg. water (including a source of distilled or ionised water for rinsing of bronchoscopes) and electricity, quality of management, if equipment is appropriate for needs and fit for purpose, what is required of the equipment in the near and far future (relocation?), compliance with S.A. National Standards for CSSD, compatibility of equipment and devices, correct chemicals, maintenance of equipment, training of operators. Although the use of disposable breathing circuits and accessories (masks) should be encouraged, the capacity to disinfect these items if disposable is not available must be considered.

The CSSD must be sized to serve the ACS. Considerations are workload and space requirements. CFSA has extensive [https://www.fidssa.co.za/Content/Images/CFSA_SOP_2018.pdf standard operating procedures] for CSSD.

Workload: Number and type of procedures, number of procedure rooms, eg for bronchoscopy, operating hours, available inventory, volume of work and peak times, degree of mechanization, eg. manual or automated instrument washing, amount of product to be stored – chemicals, barrier wrap, chemical indicators, etc., storage and distribution records, quality records – eg. equipment checks, disposal needs.

Space requirements: Space for separation of clean and dirty, allow for unidirectional movement, allow space to manoeuvre trolleys (queue, pack/unload), reduce lifting and carrying heavy items, reduce awkward movements, allow for tidy work areas. Insufficient space will compromise sterility!

Preference should be given to construction materials and finishes which are suitable for frequent cleaning and tolerant to chemicals, including bleach (sodium hypochlorite). Impermeable flooring, non-slip and smooth washable walls are needed. Joints at walls and floors and coving at wall edge, and exposed drains should be avoided. Worktops should be sealed and should be ergonomically suitable.

Ceiling heights below 2.8m may be vulnerable to damage from humidity Where steam and moisture are generated. Noise – insulation of washer-disinfector and steriliser in technical walls will reduce noise. Lighting: Natural light if possible – windows sealed. High luminance if artificial lighting. Open, slatted shelves for sterile store area. Sinks for manual washing: At least two basins, deep (25cm at least) basins, 91 cm from floor, wide and long enough for the biggest instrument tray or container, water ports for flushing of lumens.

The CSSD space allocation and layout should be determine based on what procedures and which medical devices will be required. A typical [[equipment list is provided here]].

=== Maintenance and cleaning ===
Maintenance and cleaning services must be accommodated with offices located away from clinical areas.

=== Mortuary services ===
The National Department of Health has issued guidance on handling of dead bodies and infectious remains<ref>National Department of Health South Africa, 2020 [https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf]</ref>, which should be applied to ACS. While some guidelines have recommend that bodies of persons who have died from COVID-19 should only be held for a very brief period prior to cremation or treatment for burial<ref>Zhejiang University, 2020 [http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm]</ref>, the WHO holds the view (at the time of writing) that there is no evidence of persons becoming infected from exposure to bodies during normal ceremonial and burial activities. However, appropriate PPE should be used when handling such bodies with additional airborne precautions to be taken during autopsies<ref>WHO, 24 March 2020 [https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf]</ref>.

Either body cabinets or a refrigerated room could be used for body storage.
==== Location and layout of mortuary service ====
It is likely that not all alternative care sites will have a mortuary. Those without a mortuary must have a holding room that is located away from general access areas. This holding room must be suitably sized and conditioned. A recommended room size is 3.5 m x 3.4 m<ref>IUSS Adult Inpatient Services, 2014, [https://www.iussonline.co.za/docman/document/clinical-services/65-adult-inpatent-services-gazetted/file]</ref>
A mortuary should be located so that it is easily accessible to mortuary staff and related service providers and visitors without presenting either aesthetic, emotional or ethical problems for unrelated staff, patients or visitors. It should be separate from the general facility, allowing access for the family to view a body without passing through any potentially contaminated area of the facility. The visitors’ entrance should be external and completely separate from other access points.
Appropriate routes should be designated so that bodies are not moved through public-access areas.
==== Sizing of mortuary ====
The layout and size of a mortuary are largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.
==== Services ====
The following services are required in a mortuary:
* Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.
* Sluicing facilities are to be provided in both the body-preparation and autopsy areas if they are not a common area.
* Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush-fitted stainless steel grids.
* No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.
* The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.
* Anti-backflow devices should be fitted to the water-supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.
* Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.
==== Finishes ====
Wall and floor finishes should be impervious to liquids and easily cleanable.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Environmental Controls''' ==

== '''General Indoor Environment Conditions''' ==

Existing environmental control systems should be modified to suit requirements in the facility. The following issues should be considered:
* Systems should be set to maximise the introduction of fresh air and maintain the pressure regime (see ventilation).
* The following internal temperature range should be maintained 19 - 24oC.
* Cooling systems should be able to cater for projected internal heat gains from people, lighting and equipment. Indicative heat gains in treatment areas are 8W/m2 from people, 15W/m2 from lighting and 3 W/m2 equipment and in critical care areas 16W/m2 from people, 15W/m2 from lighting and 60W/m2 equipment.
*As heat gain can vary widely between items of equipment, heat gain and utilisation rates for equipment should be obtained from the manufacturer to establish this more accurately.

=== Solid waste from ACS ===
According to the National Department of Health COVID-19 Environmental Health Guidelines
“All solid waste from the facility should be regarded as potentially infectious material and therefore appropriate precautions should be taken". The management of healthcare risk waste (HCRW) should follow the correct identification segregation, storage and disposal processes as indicated in SANS 10248-1.

* HCRW is segregated at the point of generation and shall be containerized to minimize the risk of contamination.
* Waste generated from patients in isolation or quarantine in a designated facility health facility is treated as health care risk waste (HCRW) as per SANS 10248-1-2008.
* The HCRW is properly packaged in a sealed, leak and puncture-proof containers/ boxes.
* The HCRW is labelled with the biohazard symbol/ sign and marked “Corona virus or COVID-19”.
* The HCRW is stored separately from other waste generated.
* The collection, transportation, treatment and disposal is provided by only an appointed/ appropriate contractor/ service provider, however, ensure that waste is safely stored until the health care waste management company can pick it up and that the company knows and acknowledges that waste was generated by suspected or confirmed COVID-19.
* The waste management company collecting must ensure that and treated and disposal is conducted at license waste treatment/ disposal facilities .
* All personnel or staff in contact with patients must be geared with appreciate personal protective equipment (PPE’s) at all times to prevent exposure or risk to health.
* Monitoring should be done at such facilities.
* All, bags, bins and boxes must be adequately sealed, as not to leak any fluids, and must be wiped down with 0.05% chlorine solution

Measures developed should consider the following.
* Develop a waste management plan following national guidelines and best practice standards for the disposal of medical waste (WHO, 2020).
* Establish procedures with medical waste service providers to regularly pick up the waste and dispose of this safely.
* Provision should be made for 5kg of solid waste per bed per day and this should be monitored and supplemented where it appears this may be inadequate.
* Ensure that access to waste is secure and controlled, for instance, by using lockable waste 1000l containers kept in a location that can only be accessed by health facility and nominated service delivery staff.
* Vermin control programs must be implemented throughout the site with HCRW collection points prioritised
* Provision for safe cleaning and disinfection of reusable containers should be provided. Cardboard, single-use HCRW boxes are removed from site and incinerated.
* Waste must not be allowed to accumulate or be stored inappropriate or unsecured containers.

== '''Engineering Services''' ==
Engineering services include patient services, ventilation, electrical power, water, medical gases, oxygen, compressed air, vacuum, lighting, and fire safety that support the needs of the patients and medical staff under normal and emergency situations. Good practice standards are provided in:
* IUSS Building Engineering Services<ref name = "IUSSBES">IUSS 2017, [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file]</ref>
* NHS Nightingale Instruction Manual<ref name="BDP2020">BDP 2020, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf]</ref>.
The guidance below draws on these and other manuals and standards. 

=== Building ventilation ===
==== Mechanical ventilation ====
While SARS-CoV-2 RNA has been detected in aerosol form, in experimental mechanical aerosolization studies, it is primarily spread through droplet and contact spread and the potential for airborne transmission is thought to be low.
However, the following advice is provided by ASHRAE regarding HVAC systems in general spaces (not specific to healthcare):
Effective high levels of ventilation must be achieved in the facility. Existing ventilation systems should be tailored to suit internal layouts and requirements and the following measures should be taken.
* Mechanical systems should be set to maximise fresh air supply to the facility. There should be no recirculated air without HEPA filtration or other validated decontamination processes.
* A pressure regime should be established, as shown in figure 2, to 'push' air from clean areas, to dirty areas and then out of the building.
* A clean air supply of over 10 L/s per person should be targeted for odour control.
* Fresh air supply shall not be located near patient beds to avoid drafts in winter.
* Extraction points can be located near patient beds in isolation wards or at a high level in long-stay wards. Short-circuiting of air between high-level supply and extraction is a performance risk in winter.
* Noise from ventilation systems and fans shall be below 45 dBA
* Protected lobbies, internal partitions, door arrangements, fans and extracts should be used to maintain the pressure regime and airflow as indicated in the diagram below.
 

[[File:Ventilation in temporary facilities.png|600px|thumb|none|Ventilation in temporary facilities<ref name="BDP2020"/>]]

==== Natural ventilation ====
The airflow direction between naturally ventilated zones may fluctuate according to the wind direction. This is not of concern within and between contaminated zones where occupants are either protected with mandatory PPE or confirmed to be infected with disease strains similar enough so as not be able to reinfect others. Where levels of occupant susceptibility to an airborne disease is significantly different, the less susceptible areas (such as PUI areas and uncontaminated areas) shall be protected from the naturally ventilated and contaminated areas by mechanical ventilation systems with a capacity sufficient to overcome the expected natural ventilation pressure fluctuations (typically 5-15Pa). Where such mechanical ventilation systems are not feasible or expected wind pressure is too great, zone adjacently must be avoided.

===Ultraviolet germicidal Irradiation===
The application of Ultraviolet Germicidal Irradiation (UVGI) for room air disinfection is well understood and is proven to be effective in the disinfection of microorganisms including M. tuberculosis (TB) in air. UVGI should, therefore, be considered as a valid element in indoor airborne infection control strategy for high volume settings. Studies have demonstrated the importance of good vertical air mixing in the room, and the safety of UVGI application. In areas where UVGI is indicated, the design and development of UVGI systems should be in accordance with the [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]<ref>van Reenen et al,2019 [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]</ref>

=== Electrical power ===
Sufficient and reliable power must be available at the facility for envisaged medical equipment, medical gases, lighting and building ventilation equipment. Power installations for the temporary facility can be divided into three zones as indicated below. These are existing services, the temporary service zone and services in each bay.
The following should be considered by competent engineering professionals.

=== Existing services ===
*Capacity: Evaluate whether sufficient power to accommodate envisaged medical equipment, additional lighting and heating, building ventilation and air conditioning can be provided. If existing capacity is insufficient, investigate if it is possible to route additional power from additional locations/transformers around the site or from adjacent sites.
* Safety: The existing electrical distribution network must be able to supply the required equipment load. If this is insufficient/appears unreliable, identify how this can be supported.
* Resilience: Evaluate back-up power and a UPS capacity against essential services demand. If existing capacity is not sufficient, source and establish temporary service capacity.

=== Temporary service zones ===
*Identify locations for temporary service zones where equipment can be located.
*Ensure that equipment and maintenance access is safe and easy.
*Ensure that all distribution boards, circuit breakers and cables are clearly labelled.
=== Services in each bay ===
*Provide pre-wired power strips/trunking as per bay requirements.
*Check that these include sufficient electrical outlets and service points for envisaged equipment.
*Ensure that trunking will carry required equipment loadings. The IUSS Building Engineering Services Guide can be used to check requirements<ref name = "IUSSBES"/>.

[[File:Layout_of_power_in_a_temporary_installation.png|600px|thumb|none|Layout of power in a temporary installation <ref name="BDP2020"/>]]
----

=== Water ===
Water points are needed for handwashing, showers and cleaning. The following issues need to be taken into account.
==== Supply ====
Onsite cold water storage, dedicated to the domestic water requirements of the facility, should be provided. A minimum usable volume of 500 litres per bed should be available.
Hot water storage and consumption should be confirmed by an engineer, as follows:
*Storage 25 L per bed.
*Consumption 180 L/bed.day W/O laundry; 250L /bed. day W laundry.

==== Handwashing ====
See infection control for clinical wash-hand basins
==== Showers ====
Showers for staff coming off shift should be available. Staff flow routes exiting contaminated treatment areas should pass through gowning and shower areas.
----

=== Medical gases, oxygen and vacuum (suction) ===
Medical gases, oxygen and vacuum services will be required in the facility. Mobile gas supply requires piping between supply and patient and clutter floor space. Preferably used fixed installations for patient rooms/cubicles, if possible.

System capacity and point of use pressures and consumption rates are to be ensured at all points. WHO provides technical guidance on [https://www.who.int/publications-detail/oxygen-sources-and-distribution-for-covid-19-treatment-centres oxygen sources and distribution]. 
[[File:Medical gas service layout.png|6oopx|thumb|Medical gas service layout<ref name="BDP2020"/>]]
The following points should also be taken into account.
* For centrally supplied medical gas and vacuum services, system resilience and availability must be ensured.
* Compressors, tanks, accumulators, VIEs, headers and controllers must be secured from uncontrolled access.
* Where possible, gas piping should be reticulated below floors or in ceilings to ensure protection from tampering, damage and ease of access.
* Where reticulation is within open areas, high-level reticulation with point-of-use droppers is advised. Low-level reticulation within rooms is to be avoided.
* Flexible piping can be used, ensuring it does not present a contamination or fire risk and should comply with local regulations. Special care should be taken with flexible O2 piping, keeping it to a minimum.
* Vacuum piping may be contaminated, where point-of-use filtration and collection systems fail. Precautions should be taken when demounting or disconnecting temporary vacuum lines.
* Ensure that oxygen pipelines are designed to provide sufficient flow to all oxygen points in the facility. In terms of utilities, oxygen and medical air would be required. A temporary vacuum point can be provided by mobile medical vacuum units distributed throughout the unit.
* Mobile medical air supplies should be considered where reaching piped specifications are not feasible. Where flexible hoses are used for oxygen and medical air special precautions need to be taken. Flexible oxygen piping must be chemically safe for O2 use. Where perishable flexible piping is used for medical air, terminal filtration at the point-of-use may be required at point-of-use. Especially for long-term use.
* Electrical and gas services can be reticulated against pipe racks or boards fixed to the bed-heads for head to head bed arrangements.
* Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.
* Gas service outlets to be labelled and colour-coded with 3mm lettering.
* SANS 7396-1 should be used to specify the requirements from design to commissioning of medical gas and vacuum systems.
* Medical gas and vacuum pipelines shall be marked per SANS 7396-1 and ISO 5359, as applicable.
* Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.
* SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.
* Plain-ended copper tubing for low-pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.
* Laboratory gas taps and valves shall be marked as described in SANS 10140-4.

=== Lighting ===
Existing lighting systems may need to be modified to suit the clinical requirements in the facility. High bay lighting presents inadequate colour rendering quality for the accurate detection or easy diagnosis of certain clinical conditions. This needs to be evaluated in the selection of supplementary lighting systems.
*Lighting levels should be provided in line with the indoor lighting levels recommended in the Table 6 of IUSS Building Engineering Services .
*Mobile task lighting systems may be adopted in the serious and critical stay wards to supplement incorrect lighting quality.
*Emergency lighting and illuminated emergency egress signage should be linked to the back-up power system.
*External security lighting in external parking areas and spaces around the building should be enhanced to ensure the security of medical staff who need to change shifts at night.

=== Fire safety ===
A functional fire alarm system should be available to support the patient care setting. Fire is a very real threat due to the possibility of an oxygen-enriched atmosphere developing so ventilation is crucial.
The use of temporary facilities for medical care should note the following fire risks (NHS, 2020):
*Patients may have a very high dependency.
*Areas are not specifically designed for patients and do not meet guidance on fire compartmentation and progressive horizontal evacuation.
*Large numbers of patients supplied with oxygen up to 10 litres per minute.
*Possibility of oxygen concentrations exceeding those generally found in the atmosphere- less risk if effective ventilation or large volume i.e. high ceilings.
* Possibility of storage, in excess of 40 litres, of alcohol-based chemicals (such as hand-rub), necessitating a flammables cabinet on site.
*Staff who may not normally work together .
*Staff who may not be familiar with the area.
*Staff not trained in fire safety, progressive horizontal evacuation or oxygen isolation for the specific area.
These factors should be taken into account in fire risk assessments which should then address significant findings in an action plan. Fire assessments should be undertaken by a qualified person and shared with operations and building management staff within the facility. Measures developed should include:
*An automatic fire detection system
*An emergency egress plans are prepared that include patients who have a very high dependency.
*Signage, notices and lighting are installed and are working effectively.
*Management processes are in place to minimise the risk of fire from ignition sources, fuels and oxygen.
*Staff are trained and a fire safety guide sheet for staff is developed and issued.
*Emergency egress routes are kept clear.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Additional Resources''' ==
=== [[Directory of Service Providers|A Directory of Service Providers can be viewed here]] ===

=='''References'''==
<references />

[[Category:COVID-19| ]]
[[Category:Alternate Care Sites|Alternate Care Sites]]

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[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19|(Return to Top)]] 
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Infrastructure Guidance for COVID-19/Alternate Care Sites

2020-05-08T08:37:18Z

Peta: /* Typology Dictates (Case Studies) */

[[Infrastructure Guidance for COVID-19|Return to Infrastructure Guidance for COVID-19]] 

== '''Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19'''==

This guidance work was initiated under the project titled: 
''Reducing Nosocomial and Community-Acquired Tuberculosis by Strengthening the Capacity of the South African Department of Health to Improve Implementation of Infection Control and Waste Management at All Levels of the Health System Under the President's Emergency Plan for AIDS Relief (PEPFAR)'' 

== '''Purpose and Approach''' ==
The global pandemic of COVID-19 caused by the coronavirus, SARS-CoV-2 is likely to result in a surge in need for medical care for Severe Acute Respiratory Syndrome (SARS) in South Africa. Considering the course of the pandemic in other countries, it is anticipated that South African hospitals will not have sufficient capacity to cope with the surge of persons requiring medical attention and that surge capacity via alternate care sites (ACS) will need to be established.
Surge capacity, contemplated here is not the frequent emergency department overcrowding experienced by healthcare facilities (e.g. Friday/Saturday night emergencies) or local casualty emergency that might overcrowd nearby facilities and have little to no impact on the overall healthcare delivery system. It is when a catastrophic event occurs and the affected population seek medical care from existing local healthcare facilities, causing healthcare infrastructure to become exhausted due to excess in demand. During a healthcare surge, the standard of care will shift from focusing on patient-based outcomes to population-based outcomes, and providers should anticipate “a shift to providing care and allocating scarce equipment, supplies and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals.”<ref>[https://asprtracie.hhs.gov/technical-resources/resource/491/altered-standards-of-care-in-mass-casualty-events Health Systems Research Inc., 2005]</ref> 

Surge capacity can be temporarily established in non-traditional environments, such as hotels, exhibition halls, community halls, and as field hospitals, on open spaces. 

In the context of this document, a quarantine site is a facility for patients who do not require continuous professional medical care, while an ACS is defined as a temporary facility that can provide continuous medical care for SARS. This document provides principles and considerations, high-level guidance for minimum requirements and examples for ACS. 

While an extensive set of health facility guidelines does exist<ref>[https://www.iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-servi IUSS Building Engineering Services (2017)]</ref>, these are applicable for conventional facilities and thus include services and guidelines that are not necessarily relevant to the treatment of a novel, highly infectious pathogen, with pandemic effects. Moreover, these do not provide well for the rapid and temporary establishment of facilities. 

In order to formulate high-level guidance, [[as invited by Business for South Africa]], the team reached out to professional industry bodies for inputs, in particular the South African Institute for Architects (SAIA), The Gauteng Institute for Architects (GiFA) [https://www.gifa.org.za/ Gauteng Institute for Architecture] and the [http://www.safhe.co.za/ South African Federation of Hospital Engineering (SAFHE)], by inviting input via a 36-hour research charrette. Relevant historical and contemporary literature was consulted, precedents identified and critically reviewed. An interaction with the team at Wuhan responsible for makeshift hospitals and emergency infectious diseases hospitals, Central-South Architectural Design Institute, was arranged with assistance of the Chinese Embassy. Material from the [[Infrastructure Unit System Support|Infrastructure Unit System Support (IUSS)]], international literature and guidance and input gathered from the broader architectural, engineering and healthcare professional communities was synthesised and moderated by the CSIR team. The draft was reviewed by an expert review panel. 
=== Acknowledgement of contribution ===
The contributions to the initial version of this were gratefully received. [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Acknowledgements|A list of these contributors can be viewed here.]]. 
New contributions are eagerly encouraged along with debate and discussion on the [[Talk:Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites|'''discussion forum.''']] tab above.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Scope and Assumptions''' ==
ACSs as discussed in this document are dedicated, temporary facilities for triage, testing, diagnosis, further referral and treatment of persons:
*suspected of having contracted SARS-CoV-2, (persons under investigation (PUIs)), who are symptomatic and/or are awaiting results,
*or are confirmed to be infected.
ACS will accommodate a variety of clinical, logistical, support and auxiliary services associated with the render of care. ACS will currently not be licensed to provide healthcare services. Since the ACS will operate in a non-healthcare facility, it cannot fully replace a hospital setting and its prime objective is to manage the patient load until the local healthcare system can meet demands. 

=== Exclusions ===
Quarantine facilities are accommodation facilities where a member of the community can remain for the duration of their isolation period. This is typically temporary housing for a cohort of people who do not need intensive medical attention but who cannot stay at home. Patients can take care of themselves and need limited monitoring by medical staff. Quarantine: Containing presumptive-case patients from each other and the general population.
Quarantine facilities – that is for asymptomatic persons who are in the community in self- or imposed isolation, but not displaying symptoms, or who are symptomatic, but are able to safely recover without clinical intervention and do not need continuous medical observation are not considered in this document.

=== Service regime ===
The following assumptions are made with respect to services under consideration.
* Temporary - limited to the part of the pandemic when the “conventional” hospital platform cannot meet demand. To be dismantled, thereafter.
* Uncomplicated, dedicated COVID-19 care is to be prioritised for ACS.
* Patients with comorbidities, paediatrics will be prioritised for conventional facilities, and only accommodated in ACS as a matter of last resort.
* 24 hour, 7 days a week operations. 

=== Assumed mechanism of transmission ===
Transmission of SARS-CoV-2 is understood to be from person to person firstly by [https://en.wikipedia.org/wiki/Transmission_(medicine)#Droplet_infection droplet] transmission, then by the [https://en.wikipedia.org/wiki/Transmission_(medicine)#Direct_contact contact] route and finally via airborne [https://en.wikipedia.org/wiki/Transmission_(medicine)#Airborne_airborne transmission] during or following mechanical aerosolisation. Water transmission risks are minor, occurring in special [https://en.wikipedia.org/wiki/Transmission_(medicine)#Fecal%E2%80%93oral Fecal-oral] circumstances. Reclassification of transmission mechanisms may nullify some of the approaches presented in this guidance. 

=== A call for strategic coordination ===
This document focusses on infrastructure requirements. These provisions are meaningless without staffing, equipping and resourcing. Whilst staffing, equipping and resourcing are not the focus of this document, these are likely to emerge as key constraining features. Resource constraints are likely to become acute during this pandemic. Doctors and nurses are already in critical short supply in South Africa and internationally, and are themselves susceptible to COVID-19 infection. Equipment and consumables are in short supply with heightened global demand, reduced manufacturing capacity and limits in trade flows. This necessitates strategic coordination, proactive planning, options appraisal and prioritisation. 

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Status Quo''' ==
=== Rationale and transmission status ===
According to the [https://en.wikipedia.org/wiki/World_Health_Organization World Health Organisation] (WHO), based on the largest cohort of COVID-19 patients, about 40% of patients with COVID-19 may have mild disease, where treatment is mostly symptomatic and does not require inpatient care. About 40% of patients have moderate disease that may require inpatient care; 15% of patients will have severe disease that requires oxygen therapy or other inpatient interventions, and about 5% have critical disease that requires the patient to receive mechanical ventilation. However, the evolution of the outbreak in some countries has shown a higher proportion of severe and critical cases and the need to rapidly increase surge capacity to prevent rapid exhaustion of biomedical supplies and staff. In some countries, doubling rates of cases every three days has been observed<ref>WHO-2019-nCoV-HCF_operations-2020, [https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf]</ref> 

South Africa has a high burden of disease, with a high prevalence of [https://en.wikipedia.org/wiki/HIV/AIDS_in_South_Africa HIV and TB]. Although evidence is yet to emerge of the effect of SARS-CoV-2 on a population with these pre-existing conditions, there is reason to proceed with caution<ref>The Conversation 2020, https://theconversation.com/tb-hiv-and-COVID-19-urgent-questions-as-three-epidemics-collide-134554</ref>. There is a potential direct and indirect benefit of ACS to people living with HIV and TB, as well as to general public health and the health system preservation. 

With the travel lockdown in place, and continued transmission, it appears that South Africa is on the cusp between cluster transmission and community transmission according to WHO’s classification, shown in the [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites#Key_clinical_and_infection_control_activities_for_different_transmission_scenarios_.5B3.5D|table below]], indicating that preparation should include temporary hospital facilities and mass critical care.

==== Key clinical and infection control activities for different transmission scenarios <ref>WHO 2020, [https://apps.who.int/iris/handle/10665/331492 https://apps.who.int/iris/handle/10665/331492]</ref> ====
{| class="wikitable"
|-
! !! '''No Case''' !! '''Sporadic Case''' !! '''Clusters of Cases''' !! '''Community Transmission'''
|-
| Faculty Space, Including for Transmission|| Usual Space. Enhanced Screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards). || More patient care areas re-purposed for COVID-19 within the health system, especially for severe cases || Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Staff|| Usual space. Enhanced screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards)||More patient care areas repurposed for COVID-19 within the health system, especially for severe cases||Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Supplies||
*On-hand supplies. Equip wards for COVID-19 treatment.
*Identify essential equipment and supplies, including oxygen.
*Prepare expanded local supply chain
||
*Expanded inventory of supplies with detailed protocols for use.
*Activate expanded local supply chain.
*Prepare national supply chain.
||
*Conservation, adaptation, selected re-use when safe.
*Activate contingency planning and procurement for essential equipment and supplies.
*National supply chain.
*Prepare expanded supply chain at the global level
||
*Activate contingency planning should critical equipment be in short supply.
*Determine allocation of lifesaving resources for HCWs and patients.
*Activate expanded global supply chain
|-
| Standard of Care|| Usual care with enhanced awareness and recognition of immediate needs for first COVID-19 patients|| Usual care and treatment for all patients, including those with COVID-19||Identify context-relevant core services. Shift service delivery platforms. Consider reduction in elective patient encounters, including elective surgical procedures.|| Mass critical care (e.g. open ICU for cohorted patients).
|-
| Care areas expansion|| No requirements for expansion|| Designate 10 beds per suspected COVID-19 case|| Expand COVID-19 patient care areas by a factor of 35 ||Expand COVID-19 patient care areas by a factor of 58
|}

=== Quantification of need ===
At this time there are various parallel initiatives aimed at forecasting the South African epidemic, quantifying the projected need for facilities, and a shortfall in existing capacity. At this time, there is no consensus on this. This section will be updated as further data becomes available.
ACS will prioritise mild to moderately affected COVID-19 patients where basic, targeted medical care will be provided. Should patients’ needs evolve, requiring escalation of care, then the transfer of patients from ACS sites to conventional sites of care will be needed as a matter of course, bringing with it logistical challenges and risks. In the event that the conventional hospital platform is unable to cope, ACS will have pressure to provide care for severe and critical patients, and finally for patients with comorbidity and special requirements, such as paediatrics, persons living with HIV (PLHIV), TB patients and pregnant women. The following pragmatic approach, aligned with the WHO recommended strategic approach, is suggested.
*ACS should preferably be identified with space for expansion.
*The set-up should be done so that levels of care can be upgraded to higher levels of uncomplicated care.
*A secondary upgrade for more diverse package of care may become necessary.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Strategic Approach''' ==
According to WHO, clinical interventions must be put into place immediately and then scaled up according to the epidemiologic profile.
[[File:COVID-19 Resource allocation.png|none|thumb|600px|right|WHO Strategic approach to clinical care]] 
Under this declared state of disaster, the clinical care strategy which cannot be accommodated within existing facilities, can, on a temporary basis be hosted in ACS:
*Within and around existing healthcare facilities, via reconfiguration and/or augmentation.
*In existing non-healthcare buildings suitable for repurposing, such as universities, hotels and conference centres, warehouses, gyms, hostels etc.
*On open fields, including paved parking areas with rapidly constructed, dismountable structures, such as modular tented structures or using rapid modular construction techniques. 

ACS will provide isolation, general (non-acute) care for patients with mild to moderate symptoms and as required, acute care for patients with severe symptoms. Containing confirmed-case patients from general population. Confirmed-case patients can be housed together en masse, while presumptive-case patients must be individually quarantined.
As shown in the WHO Strategic approach to clinical care, the WHO recommends a range of services to meet patient need (''Citation needed''). General (non-acute) care ACS model is designed for minimal acuity patients requiring minimal activities of daily living support (e.g. COVID-positive with minimal symptoms or require <2L of oxygen). Acute care ACS model is designed for higher acuity patients requiring closer monitoring or respiratory support (e.g. COVID-positive with pneumonia or respiratory distress requiring ventilator support). Paediatric patients are to be accommodated in separate wards, where strictly controlled visitation may be allowed. 
As a preliminary estimate, the following ratios of service is proposed:
[[File:COVID Ratios of Service.png|none|thumb|600px|center|COVID Ratios of Service]]

{| class="wikitable"
|-
! '''Case severity, risk factors<ref group="Notes"> Test suspect COVID-19 cases according to diagnostic strategy</ref><ref group="Note"> Known risk factors for severe COVID-19: age over 60 years, hypertension, diabetes, cardiovascular disease, chronic respiratory disease, immunocompromising conditions.</ref>''' !! '''Recommendations'''
|-
|Mild || Patient should be instructed to self-isolate and contact COVID-19 information line for advice on testing
and referral.
|-
|Moderate, with no risk factors ||Test suspected COVID-19 cases according to diagnostic strategy. Isolation/ cohorting in:
* Health facilities, if resources allow;
* Community facilities (e.g. stadiums, gymnasiums, hotels) with access to rapid health advice
(i.e. adjacent COVID-19 designated health post/EMT-type 1, telemedicine)
*Self-isolation at home according to National guidance
|-
| Moderate, with risk factors || Patient should be instructed to self-isolate and call COVID-19 hotline for emergency referral as soon as possible
|-
|Severe || Hospitalization for isolation (or cohorting) and inpatient treatment.
|-
|Critical|| Hospitalization for isolation (or cohorting) and inpatient treatment.
|}

=== Notes and References: ===

<references group = "Note" />
<references />

=== Typology dictates & case studies) ===

[[File:NHS Nightingale Hospital London.png|thumb|NHS Nightingale Hospital London <ref name="NHS Nightingale Hospital London">Coronavirus: Building NHS Nightingale Hospital London, 2020 [https://www.bbc.com/news/in-pictures-52092253 https://www.bbc.com/news]</ref>, ]]
To meet the requirements set out in this guidance, prospective “host” sites should be carefully evaluated. The type of “host” site selected will strongly influence or dictate the choice of ACS service model.

No site is likely to meet all requirements and recommendations set out in this document. Adaptations and compromises will be necessary. Services should be provided on site where it is pragmatic to do so, for example where similar services are provided. Outsourcing can also be practical/feasible for some services, such as laboratory services, catering and laundry, provided suitable logistical arrangements can be made.

Some typological responses and service models are set out in precedent examples, shown below. The examples demonstrate that a variety of host settings are workable, provided that the appropriate utility can be contrived. Other than in metroplitan areas, co-location of ACS on the premises of, or adjacent to existing halthcare facilities will often be preferable because this is where intensivists and specialist clinical staffing will be available, and support services may be well established. Nevertheless, augmenting capacity at existing facilities should take into account current workloads and capacity to ensure that the COVID-19 surge disrupts normal service provision as little as possible, including continuity of care for patients with chronic conditions and TB and HIV patients. 

*'''[[Infrastructure Guidance for COVID-19/Alternate Care Sites/Case Studies|SARS ACS Precedents and Case Studies can be found here]] '''

=== Notes and References ===
<references />

== '''ACS Infrastructure Planning''' ==

=== '''Establishing a team''' ===
A planning team should be formalised to establish the minimum planning and operational requirements for the ACS and to liaise with the local community. The team should include individuals with expertise in the following areas (ideally with knowledge of healthcare delivery under emergency conditions):
*Disaster response / emergency management coordination,
*Clinical care and staffing,
*Infection Prevention and Control practitioners must be involved in all stages of planning, commissioning, in-use, and decommissioning of the facility
*Facility set-up, operations and management,
*Security,
*Transport (patient, staff),
*Engineering and project management,
*Procurement and coordination of supplies, equipment and pharmaceuticals, and
*Community liaison to ensure that concerns of the adjacent population on understood an addressed.
It is important to ensure compliance with health, safety and building regulations, by ensuring the involvement of relevant local authorities. Stakeholder engagement should be formally documented. Concerns and grievances should be systematically addressed.

=== '''Structural integrity and operational responsibility''' ===

'''Structural modifications:''' ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered. 

'''Competent person:''' All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed. 

'''Asset responsibility:''' Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented. 

'''Integrity and responsibility'''

'''Structural modifications''': ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered.

'''Competent person''': All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed.

'''Asset responsibility''': Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented.

'''Decommissioning''': Decommissioning of the facility shall be assigned to the competent person discussed above. All residual structures upon decommissioning shall comply with the National Building Regulations. Upon decommissioning, removal of equipment shall be the responsibility of the owner. An infection prevention and control practitioner should be engaged in the decommissioning phase to oversee terminal cleaning and disinfection of equipment and premises.

'''Closure''': Once all patients can be safely discharged or transported back to existing facilities for continued care and there are no ongoing healthcare surge capacity needs, the ACS can be closed. Shut down of an ACS will require decommissioning, identification of new homes or storage for equipment, and termination of ongoing contracts or arrangements. Shut down should be expedited so that the facility can quickly be returned to the control of the existing owners and returned to its usual function.

Action checklist items for ACS closure should include, but not be limited to, the following:
*conduct a site walk-through with the facility owner when shutdown activities are completed to ensure that terminal cleaning and disinfection of supplies and premises, removal of equipment and supplies, and other surge closure activities have been completed to the owner’s satisfaction.
*perform medical records storage procedures.

== '''Site Selection''' ==
When selecting a site, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital can be utilised to determine whether the site is suitable for a 100, 1000 or 2000 bed facility, as required. The following indicative minimum site sizes are needed:
*100 Bed ACS/ hospital conversion, requires ± 4 300 m2
*1000 Bed ACS/ hospital conversion, requires ± 17 600 m2
Evaluation should be done by examining plans (if available), satellite images, drone images, scans and by physical inspection (walkabout). A comprehensive photographic survey should be undertaken and retained for record purposes on the site inspection. This will serve as an audit record and may assist in returning the site to its original function on ACS decommissioning and closure. When scrutinising documents and conducting site inspections to confirm the suitability of a site to host an ACS, the following criteria should be taken into account.
=== Criteria ===
*Affordability (costs, including operational costs known and budget identified),
*Sufficient physical space and capacity to house the immediate need, with the potential to accommodate physical space requirements. For example, open site should not be sloping,
*Legal rights and encumbrances, including renewal opportunity,
*Good access to highway and main roads,
*Well secured perimeter and limited controlled access points,
*Proximity to other hospitals and care sites,
*Accessibility for key staff and public transport,
*Good vehicular access around the site to set up temporary equipment such as back-up generators,
*Free from clear and present danger,
*Outside attenuation zones, floodplains,
*Outside high wind zones,
*Structure in good repair,
*Effective onsite facilities management team who understand how systems work,
*Potential for expansion, if required,
*Access to sufficient capacity for
**potable water,
**adequate sewage,
**telephone,
**internet access with sufficient bandwidth,
**electricity,
*A zone for cleaning, disinfection, and decontamination of equipment at least 15 metres away from occupied areas with access to water, a hard impervious surface and drying areas in the sun, with runoff discharge into the sewer and not into marine ecosystems or the environment. Include area for cleaning and storage of cleaning equipment.
*Likelihood of acceptance of hosting an ACS by the adjacent and local community

=== Desirable ===
*Durable, cleanable surfaces,
*Large open spaces that can be converted to accommodate temporary structures,
*Good ventilation,
*On-site kitchen and laundry,
*Housekeeping staff (chemical and equipment storage, lockers, rest facility, administration office),
*Space conducive for staff respite area and locker rooms,
*Amenities with universal access,
*Fire protection safety and equipment,
*Elevator access for patients if the building has more than one floor,
*Capacity for expansion, and
*Accessible to at least two roadways to provide continued access in the event that one roadway becomes blocked on inaccessible.

== '''Infection Prevention and Control''' ==
General guidance for COVID-19 [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|Infection Prevention and Control]] can be accessed [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|here]] 

Infection prevention and control in the context of COVID-19 should respond to transmission routes of primary concern for the pathogen of interest (droplet and contact transmission, and management of risk waste) as well as infection risk of a general nature (water and sewerage, airborne transmission – under high TB/HIV burden, and general waste).
In addition to satisfying [https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html standard precautions for all patient care], transmission-based precautions should focus on three pillars: exposure reduction by spatial configuration, operational strategies, and personal protection.
=== Transmission-based precautions ===
'''Droplet and contact spread''': Transmission of SARS-CoV-2 virus occurs via droplet and contact spread. The virus has been shown to persist on surfaces for extended periods of time and is known to be efficient at infecting people. 

'''Medical waste and linen:''' As SARS-CoV-02 is carried in body fluids and faecal matter, disposal of contaminated items (tissues) and cleaning regimes (spaces, garments, linen) should be accommodated carefully in the workflow design and infrastructure provision. A site-specific waste management plan should be formulated in accordance with a site-specific waste management plan with reference to SANS 10248. 

'''Airborne transmission:''' Under exceptional circumstances, the risk of airborne transmission arises for SARS-CoV-2, as detailed below.
{| class="wikitable"
|-
!Airborne Transmission Risk Factors
|-
|
As SARS-CoV-2 is not considered airborne, respiratory protection against airborne transmission is not considered necessary, except where aerosolisation of particles may be a risk.
According to the CDC
*tracheal intubation,
*non-invasive ventilation,
*tracheotomy,
*cardiopulmonary resuscitation, or
*manual ventilation before intubation and bronchoscopy.
According to doctors in the field also when performing
*COVID-19 diagnostic sampling as patients can be induced to cough and sneeze.
*Suspected or confirmed comorbidity of TB is not an additional risk where correct COVID-19 PPE is applied.

|}
South Africa has a high prevalence of TB and HIV, and therefore, although the risk of COVID-19 transmission via the airborne route is not paramount, there is a high likelihood that undiagnosed TB infectious patients may present at the ACS for treatment. TB triage may be challenging in the ACS as there are symptoms in common (coughing) with COVID-19. This country-specific risk is taken into account in this guidance

=== Additional precautions ===
'''Water and sewerage contamination:''' The International Water Association [[Infrastructure Guidance for COVID-19/Alternate Care Sites/COVID-19 A Water Professionals Perspective|concluded]] that water and sewerage contamination is not considered to be a key risk factor for COVID-19. The panel expressed concern for “how waste and specifically wastewater (medical) would be handled by places (e.g., hostels, hotels) that are used to serve as interim COVID-19 quarantine or testing facilities or accommodation ([ACS]. These are places other than hospitals that are used in the interim for such purposes and do not usually handle wastewater from medical settings. Such facilities should be monitored carefully.” 

== '''Spatial strategies for infection prevention and control''' ==

=== Restricted access and zone control ===
The site will be arranged to establish clear zoning, with a clear restricted zone protocol and access protection. Zones should be deemed to be "contaminated" or "uncontaminated" with clear transition areas between them.

; Contaminated zones
: (also known as "dirty areas") are areas occupied by COVID-19 infected persons, PUIs, equipment, materials and supplies which have come into contact with such persons without yet undergoing a decontamination procedure. These areas will include patient ward areas and ablutions, patient admissions (including ambulance drop-off) and the associated clinical areas. Staff rest and dining facilities should be outside the contaminated zone. Limited stock for immediate use should be kept in the contaminated zone. Layout designs should consolidate contaminated zones as far as reasonable, and avoid uncontaminated zones as islands in contaminated zones.

; Uncontaminated zones
: (also known as "clean areas") are areas not generally occupied by PUIs or confirmed COVID-19 infected persons. Equipment, materials and supplies in these areas have not yet come into contact with contaminated zones or have undergone a decontamination procedure. These will include clinical management planning rooms, stock rooms, bulk stores, pharmacy, laboratory areas, kitchen and laundry.

; Transition zones
: (also known as intermediate zone) are the spaces through which transfer of people and goods from uncontaminated to decontaminated zones, and vice versa, occur. Materials from the contaminated zone should be decontaminated or contained in the transition zone. The transfer of goods and persons should be highly ritualised and, as far as possible, traffic across transition zones should be minimised. Transition areas should be strategically located to serve this function. Separation of in-going and out-going transfer of goods and persons is preferable. Transition areas include ambulance, trolley decontamination, CSSD, laundry and waste bagging areas, patient locker area and staff change areas with spaces for donning and doffing of PPE.

=== Site layout and master-planning ===
Spatial configuration and layout can ensure unnecessary cross-over of function is avoided. This entails the systematic separation of functions and the managed transition between activities to facilitate consistency of care, an orderly, efficient work environment, less waste and reduced risk for improved outcomes. To achieve this, functional relationships should first be considered at the site level before being considered at the building level. 

<gallery mode=packed heights=300px style="text-align:left">
Layout for a SARS facility, clustering functions with minimised cross-over.png|center|thumb|Layout for a SARS facility, clustering functions with minimised cross-over <ref name="Layout1">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Layout_for_a_Patient_cohorting_strategy.png|center|thumb|Layout for a Patient cohorting strategy <ref name="Layout3">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Tygerberg Hospital virus triage unit site layout.png|center|thumb|Tygerberg Hospital virus triage unit site layout <ref name="Western Cape Provincial Government, 2020a">Western Cape Provincial Government, 2020 a</ref>
</gallery>

The WHO's Clustering Layout <ref name="Layout1"/> and Tygerberg Hospital virus triage unit<ref name="Western Cape Provincial Government, 2020a"/> show worked examples of building and site layouts, which are configured with these principles, respectively. '''Cohorting''' is defined as clustering patients with similar or compatible clinical needs together for risk reduction, acuity, efficiency and quality management, as illustrated in WHO's Cohorting Layout <ref name="Layout3"/>

=== Workflow ===
Within individual functional zones, the workflow activities can be arranged to proceed from clean procedures to contaminated procedures. In the example below, the staff arrival, PPE donning, doffing and patient flows are worked to have controlled interaction and minimised cross-over

<gallery mode=packed heights=400px >
ACS HCW Flow.png |ACS Health Care Worker Flow
COVID-19 Workflow in small unit.png |COVID-19 Workflow in Small Testing Unit <ref name="Western Cape Provincial Government, 2020b>Western Cape Provincial Government, 2020 b</ref>
COVID-19 Workflow in large unit.png |COVID-19 Workflow in Large Testing Unit <ref name="Western Cape Provincial Government, 2020b"/>
</gallery>

As far as possible, a single direction flow of clean to dirty is recommended for all processes: support services, supply and waste.
The Small ACS unit workflow diagram<ref name="Western Cape Provincial Government, 2020b"/> illustrates the recommended separation of access and exit, separate waiting seats, for persons who may be COVID-19 infected. Separate spaces are provided for donning and doffing PPE. Staff change areas are provided.

In the Large ACS unit workflow diagram <ref name="Western Cape Provincial Government, 2020b"/>, there is a clear separation between staff areas and patient areas. Waiting seats are set far apart to reduce transmission risk. Staff change rooms are provided near the point of entry to the facility for staff to change from street clothes into medical work clothes. To prevent work clothes worn inside the facility from contaminating street clothes, these are kept in separate lockers. A step-over barrier from dirty to clean sides of the change room is helpful to enforce a mind-set of avoiding cross-contamination. Bins for contaminated garments are to be provided in change rooms. Shower facilities are to be provided for staff.

== '''Operational Strategies''' ==
=== Cleaning, disinfection and decontamination ===
Surface and substrate specification, and detailing of all areas should, as far as possible, allow for frequent:
*Cleaning with detergent and water.
*Disinfection with 75% alcohol solution (metal surfaces).
*[https://en.wikipedia.org/wiki/Sodium_hypochlorite Sodium hypochlorite] (1,000 ppm)/ Household bleach.
*Disinfectants listed on the EPA List N<ref>The United States Environmental Protection Agency, [https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 List N: Disinfectants for Use Against SARS-CoV-2 (Last Visited 2020) ]</ref> (for non-critical environmental cleaning).
*High-intensity ultraviolet surface disinfection (UV-C).
*Decontamination and sterilisation of clinical equipment.

=== Goods and waste management ===
Remove any unnecessary furniture, equipment and paraphernalia from all patient care and clinical areas. Provide a clear, secure space for waste management. Any potentially infectious waste materials generated at the ACS should be considered and treated as medical waste (health care risk waste). The applicable legislation is:
*[https://www.gov.za/sites/default/files/gcis_document/201409/35405gen452.pdf The National and Provincial Health Care Risk Waste Management Regulations].
*[https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf National Department of Health COVID-19 Environmental Health Guidelines.]<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>
Waste disposal bins should be positioned near the exit inside each patient rooms or wards to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another patient in the same room.

=== Materials and finishes ===
Floor materials must be:
*Level,
*Free of dust and oil,
*Impervious and smooth,
*Slip-resistant in wet areas (e.g. patient ablutions).
Smooth, cement screed floors are acceptable. Where hosting facilities have carpeted areas, a risk assessment of factors such as durability, hygiene and decontamination needs to be conducted. In cases where the acceptance of carpeted flooring is contradicted (but other factors make it a compelling option), temporary floor finishes or covering can be investigated.

== '''Personal protection''' ==
=== Hand sanitation ===
Where wash-hand basins are not provided, clinical wash-hand basins should be installed, at the minimum rate of provision of one wash-hand basin per 5 beds. Clinical wash-hand basins (see figure below) have a variety of features not present in standard wash-hand basins, which are preferable for infection prevention and control. Where standard wash-hand basins are provided, an upgrade is not necessary. In all cases, there should be no surfaces and no clutter, equipment or supplies in the vicinity of wash-hand basins, including surgical gloves.
<gallery mode=packed heights=400px>
Clinical hand wash basin.png|Handwash Basin <ref>de Jager 2020</ref>
Portable Wash-hand Basin.png|Portable wash hand basins can be provided in ACS <ref name="BDPa">BDP 2020, NHS nightingale instruction manual, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf</ref>
</gallery>

Where wash-hand basins are not available, portable units can be used, as shown above<ref name="BDPa"/>. Mounted brackets for hand sanitisers are to be provided for every two beds, preferably mounted near the foot rather than the head of the bed and at all common touch points such as entry points at ablution facilities, linen room, sluice, storerooms, medicine rooms/cupboards, near refrigerators, telephones, light switches, at entry/exit doors, etc.

=== Personal protective equipment ===
Donning and doffing points for personal protective equipment, and convenient, safe disposal of consumables to be placed at critical key points when entering patient areas.
----

== '''General transmission mitigation''' ==
=== Water and sanitation ===
To comply with National Building Regulations; Hazardous Biological Agents Regulations and National Department of Health COVID-19 Environmental Health Guidelines<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>.

=== Droplet aerosolisation ===
When designating areas for procedures during which aerosolization and airborne transmission risk is high, the building ventilation must be carefully considered to take into account downstream risks. In particular, consider to where potentially contaminated air, arising from aerosol-generating procedures, is exhausted. In general, air exhausted directly to the outside is diluted and considered safe, unless there are openings to occupied spaces near the exhaust air outlet. 

In the event that potentially occupied spaces will receive partially diluted or undiluted contaminated air, or where this is indeterminate, the aerosolising activity should be designated to an alternate area. In the event that an alternative is not available, some treatment regime (air filtration or air disinfection) is necessary. 

In most naturally ventilated settings, the airflow direction between zones may fluctuate according to the wind direction. Such high-risk spaces should not be adjacent to spaces with high susceptibility rates, such as PUI areas and uncontaminated areas. Contaminated areas should not be directly adjacent to clean areas unless mechanically ventilated. 
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|Guidance on COVID-19 building ventilation design is provided here]].

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Health, Safety and Well-being''' ==
In addition to the infection prevention and control measures discussed above, the following should be provided for health, safety and well-being.
=== General provisions ===
*Minimised and controlled entry and exit points, with suitable control.
*Clearly identified accessible and marked routes for patients, staff, goods and waste.
*Clear designation of restricted zones.
=== Site level provisions ===
*Safe staff parking and arrival of staff via planned and public transport.
*Clearly demarcated parking for people with disabilities.
*Arrival and departure point for patients via public transport, passenger vehicles, and emergency service.
*Limited safe patient parking.
*Supply of goods and removal of waste.

=== Within and between buildings ===
*Entrances with a clear opening width (CoW) of at least 900mm.
*Routes with a minimum width of 2 000mm free of hazards, for example, rubbish bins.
*All clinical, patient and support areas to be accessible by trolley.
'''Ramps''' should be of stable construction, capable of sustaining a mass of 300kg. They should incorporate side lips and the surface should be slip-resistant. Gradients should be as gentle as the circumstances allow. (Recommended maximum 1:20). 
'''Small changes in floor levels''' are not desirable, but where these exist are to be clearly marked with reflective paint/ tape, and lit at night
Elevators between different floors, where patients need access (The recommended minimum lift size for patient trolley/stretcher movement is 1 400mm × 2 400mm, however, this may not be possible). 
'''Pathways''' to be lit at night, where used at night. 
'''Staircases''' must be well-lit at night with non-slip surfaces and secure balustrades. 
'''Doors''', Double doors and automated or push-operated doors to all clinical areas are to be preferred, where these are newly installed or able to be retrofitted. Door closers are to be disabled, where not necessary to reduce touch surfaces. Hand sanitisers to be provided at where high touch common surfaces occur (e.g. wall-mounted at doorways).

=== Signage ===
The appropriate level of information to facilitate legibility, orientation and wayfinding. Minimum standards, signage to be:
*Clearly visible, simple font, font size, contrasting colours, placed in the field of vision
*Washable
*Comprehensive safety signage - fire signage (exits, equipment etc.)
*Restricted areas clearly marked
*Identification signage - each patient space to be allocated a unique number and a whiteboard or perspex sheet for writing the patient’s name
Signs should be posted immediately outside of patient rooms indicating appropriate IPC precautions and required personal protective equipment (PPE).
Signage of a temporary nature can be provided on laminated white A4 sheets attached eye-level. The text should be black sans-serif (for instance Arial) text at least 40point size and centrally positioned on the sheet. Detailed guidance on signage is provided in IUSS Inclusive environments.
=== Safety and security ===
Upon identification of the ACS host site, a team should be convened to conduct a multidisciplinary safety and security analysis. These critical team members need to form the working committee responsible for undertaking the detailed assessment of the existing facility’s security. They should analyse data about the security system’s condition and review existing security concerns or issues that are reasonably likely to become concerns in the near future. The figure below represents a five-zone approach to security, which is a recommended, systematic approach to security.
[[File:Zonal approach to security.png|center|600px|thumb|IUSS Security- Zonal Approach to Security <ref name="IUSS Security">IUSS Hospital design principles - Security [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file]</ref>]]
The security strategy should take into account that whilst clinical services and some logistical and support services will be required 24 hours a day, seven days per week, some support services, logistics services and auxiliary services may only be operational for the minimum periods required to meet demand. These functional elements should be capable of being secured, for example over weekends and at night, as the case may be.
Detailed guidance is available in [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file IUSS Hospital design principles - Security] <ref name="IUSS Security"/>

=== Comfort and dignity ===
Supplemental heating: Patient health and comfort are dependent on, amongst others, maintaining body temperature. The ACS structural technology must be selected to achieve the general indoor environment conditions discussed in a subsequent section for all clinical and occupied areas. As we are moving into South African winter supplemental heating may be required, especially in the evenings, in order to avoid hypothermia. Use of fans, bar, radiator or gas heaters should be prohibited. Unless clinical areas can be maintained above 18 degrees centigrade, patients should each have an infrared heater available, in addition to blankets. Personal/ donated blankets can be considered if they are laundered first and could be destroyed upon discharge.
Mobile screens should be available to provide privacy where necessary (e.g. during consultations or procedures).
<gallery mode = packed heights = 400px>
Bed_Isolator_-Vietnam.png|thumb|Flexible Barrier Isolator<ref>WHO. (2020), Severe Acute Respiratory Infections Treatment Centre. Geneva, Switzerland : WHO- World Health Organization</ref>
ACS Cohort beds.png|ACS Cohort beds.png|thumb|Excel Centre London 04-2020 <ref>Architects' Journal 2020, [https://www.architectsjournal.co.uk/news/nhs-nightingale-bdp-on-the-first-nine-days-converting-the-excel-centre/10046749.article https://www.architectsjournal.co.uk/news]</ref>
</gallery>
Some solutions which address patient privacy and dignity are depicted above.

=== Notes ===
<references/>

== '''Schedule of Accommodation''' ==
Based on clinical needs of the ACS, a schedule of accommodation can be crafted capturing the clinical, clinical, logistical, support and auxiliary services associated with the render of care. When deriving a schedule of accommodation, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital tool can be used. Functions to be accommodated are: 
'''Clinical services''': Triage, rapid assessment of persons entering the facility, to expeditiously identify and render the appropriate service. Admissions and registration. Inpatient accommodation is to be organised according to cohorting principles, discussed above. Testing and diagnostics, including laboratories and x-ray. Safe storage and dispensing of drugs to patients.Offices for clinical administration and clinical planning meeting rooms in the clean zone are needed. 
'''Logistical services:''' Logistical services will entail management of flows of people, goods, services and information to and from the site, as well as within the site. It includes security and communication arrangements. Staff entry, preparations to transition from outside to clinical work environment, including pause areas for relief. Emergency services, visitors. Goods, supplies and storage and waste removal and/ or treatment.
Support services key to the provision of clinical services should be separated so that the risks associated with that particular activity can be managed. 
'''Support services are:'''
*Laboratory services
*Catering
*Laundry
*Environmental cleaning and housekeeping
*CSSD
*Maintenance and cleaning of surrounds, eg. waste areas
*Porters/”runners”, stretchers/wheelchairs
*Mortuary
* Security
Support services can be provided off-site, in which case, safe, secure and efficient transfer and logistical arrangements should be designed. 
'''Auxiliary services:''' Auxiliary services are services which may be provided on or near the ACS site, but which are not directly related to core clinical care. This included overnight accommodation for staff who may not wish to return home to avoid exposing their families, or who need rest between shifts, or for discharged patients awaiting transport home, volunteers who have recovered from SARS-CoV-2.
Limited psychosocial services and allied health services may also be provided on or near ACS for example by approved partners.
Examples of schedules of accommodation for patient and support spaces for a protective isolation ward is available [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedule for COVID-19 Isolation Wards|here]] and mild to severe cases [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedules for COVID-19 Wards for Mild to Severe Cases|here]].

== '''Clinical Services''' ==
=== Triage ===
Confirmed COVID-19 cases and PUIs who are referred from a testing facility or a higher level of care, will enter the facility in a triage area to receive vital screening and initial assessment. They will be registered and admitted to inpatient care. They will be assigned a "ward" or section of the facility - based on disease status and acuity. These are Protective Isolation, the Mild & Moderate ward, or the Critical & Severe wards. Patients should be clustered according to gender. As far as practicable, ablutions for each gender, isolation patients, paediatrics and staff shall be separately provided. Paediatrics patients, if admitted, are to be assigned a dedicated section.
As patients recover or deteriorate, they may be relocated to the appropriate section/ ward.
Once the patient has sufficiently recovered and a negative test result is received they will be appropriately decontaminated and discharged, collecting medication from the dispensary on exit. Patient movement between various sections of the ACS will be restricted as far as possible, with mobile radiology units, in-ward medication dispensing and in-ward food service.

=== Inpatient ACS accommodation ===
Separate spaces for:
*suspected, unconfirmed cases, under observation (PUIs), to be accommodated in isolation facilities (separate rooms, if possible);
*patients with confirmed COVID-19 with mild to moderate disease, not requiring dedicated oxygen therapy;
*patients who require dedicated oxygen therapy;
*patients requiring mechanical ventilation; and
*recovered/ confirmed negative.
==== Protective Isolation Facilities ====
Suspected, unconfirmed cases, under observation – persons under investigation (PUIs) to be accommodated in protective isolation facilities (separate positive-pressure rooms, if possible). PUI are restricted to their rooms. All food and laundry services will be brought to the PUI rooms to reduce interaction and potential contamination. All waste will be collected by facility staff and taken to waste handling areas. Infection prevention and control measures are put in place for the handling of used food utensil and laundry as well as waste collection. PUI areas will have restricted access, including for staff serving other inpatient sections, for confirmed cases.

==== Inpatients accommodation for confirmed COVID-19 ====

Inpatient facilities confirmed positive COVID-19 can be accommodated in large shared ‘wards’ with partitioning between patients. Partitioning between patients is optional. Partitioning is preferable to curtains found in conventional hospitals, as they are more conducive to daily cleaning. If curtains are used, antimicrobial treated fabrics with biocide used to treat the curtains has been tested to international standard EN 14476 and shown to be effective against H1N1 Influenza A Virus (Swine Flu), >99.999% kill rate in 5 minutes and measles morbillivirus, >99.99% kill rate in 5 minutes are preferred. If only separate rooms are available, patient monitoring and surveillance will need to be accommodated. This phase of treatment has a lower area/space requirement compared with PUIs, as cross-infection between patients is less of a concern. Shared ablution facilities are acceptable. It is recommended that, at least, two general accommodation ward areas be provided. 

a) Mild and moderate patients, and 
b) Serious and critical patients. 

The room must have openable windows for natural ventilation if a dedicated positive pressure ventilation system is not available. Ducted ventilation systems shall not be shared between PUI areas and confirmed COVID-19 patient areas. 
[[File:COVID-19 ACS - protective isolation – bed layout.png|thumb|center|800px|ACS - protective isolation – bed layout]]
[[File:COVID-19 ACS – mild-moderate patient bed layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient bed layout]]
[[File:COVID-19 ACS – mild-moderate patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient shared ward layout]]
[[File:COVID-19 ACS – severe-critical patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – severe-critical patient shared ward layout]]

Examples above show bed layout with bed spacing for protective isolation, a mild/moderate patient and a mild/moderate patient shared ward and for a severe/critical patient

=== Patient services ===
Patients in ACS will not generally be ambulatory and will be confined to their room, or cubicle in a bed. In general, domestic beds or hospitality industry (hotel) beds are not suitable for patient care. These should only be used where a hospital-grade bed cannot be sourced, as hospital beds are designed for ease of cleaning and decontamination (for infection prevention and control) and with patient and ergonomics, safety and comfort taken into account (they prevent back injury for nursing staff and can help to prevent bedsores). The higher the specification of bed, the more suitable it is for the higher levels of care. Lockers for patients personal belongings should be provided in the uncontaminated zone (in which case bedside lockers will not be necessary), and it is preferable (where bedside lockers are not provided) for overbed tables to be provided, per bed, if possible. 
The following beds are suitable:
*Repaired and refurbished beds from condemned hospital stocks.
*South African National Standard, SANS 521:2013 Edition 3.5, on Hospital beds and cots ISBN 978-0-626-28830-3.
*Beds listed on the National Treasury (See [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Hospital Bed Specification|specification]]).
The table below details the minimum services required at each patient bed. Details on these services are discussed in a subsequent section of the document.

{| class="wikitable"
|-
! Service/ Capacity!!Triage!!Isolation !!Mild – moderate inpatient!!Severe case wards!!Critical case wards
|-
| Power – 16A 230V Single socket outlet||As needed ||1 per bed||1 per bed||3 per bed||6 per bed
|-
| UPS Power – 16A 230V Single socket outlet ||As needed||1 per bed||1 per bed||1 per bed||2 per bed
|-
| Medical Air<ref group="Note">Mobile units recommended for intermittent use. 3 per 20 beds</ref><ref group="Note">There are some ventilators which have built-in compressors allowing them to function without Medical Air. This is however, not the norm. With Ventilators probably being the most difficult medical device to obtain at present, it would be prudent to rather allow for Medical Air at each bed.</ref> (LP)400kPa||No||Yes||No||Yes||Yes
|-
| Medical O2 -400kPa||Portable/shared||Portable/shared||No||One||Two
|-
| Vacuum-40kPa||No||Portable/shared||Portable/shared||Yes||Yes
|-
| Equipment rail||||||||Yes||Yes
|-
| Upper room UVGI||Optional||Optional||||||Optional
|-
| Examination light||No||No||Yes||Yes||Yes
|-
| Room Ventilation rate||60 L/s per person||10 L/s per person||10 L/s per person||10 L/s per person||12 ACH
|}
'''Notes: '''
<references group="Note" />

Two additional 16A 230V single socket outlets, one two-pin outlet and a worktop should be provided for every 32 beds (or part thereof), for:
*Electrocardiograph (ECG): Could be omitted if monitors have a full 12 lead ECG function.
*Blood gas analyser: Could be omitted if a Lab Services are available.
*Staff cellphone charging.

Example of healthcare technology to be provided for critical care patients is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]. Severe patients may be provided continuous positive airway pressure (CPAP). Emergency trolleys (“crash carts”) are to be provided in patient areas with convenient access to patient beds, out of the passage of corridors and is moved to the patient when needed. 1 crash cart for every 16 patients (or part thereof, with at least one dedicated for PUIs. An example of provisions for a crash cart is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]
==== Patient ablutions ====
[[SARS-CoV-2 is found in faecal matter]], so careful management of patient body fluids is crucial and convenient, practical support for frequent cleaning of ablutions especially shared ablutions is necessary. Dedicated ablutions (toilets and showers) are to be provided for patient use. Toilets and showers should be in separate rooms.
Hand washbasins and or/ hand sanitiser should be provided both inside and outside the toilet room so that patients can wash their hands on the way in and on the way out of the room.
*1 toilet for every 8 persons.
*1 shower for every 8 persons.
*1 disabled ablution for every 8 regular ablutions (or part thereof).
*1 disabled shower for every 8 persons (or part thereof).

Critical and severe patients may be sedated and have a reduced need to access ablutions, ablution facilities proximity and provision can take this factor into account. Showers and wash hand basins should have hot and cold running water. Where possible ablution facilities must have openable windows for natural ventilation, if not possible the bathroom extraction and room ventilation system must be reviewed before admitting patient '''(see [[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|ventilation]]).'''

Portable toilets and showers may be used, provided that suitable hand wash facilities are provided. These will need to be suitably located, preferably in decentralised clusters, so that patients can easily access them without needing to walk very far. Ablutions should be located and designed in such a way as to provide visual and acoustic privacy, dignity and avoid disturbance of other nearby patients when accessing, using or cleaning the ablutions. Separate ablutions are to be provided for PUIs and confirmed patients.

====Makeshift sluice areas ====
In conventional hospital settings, sluice rooms are provided for cleaning and sanitation of soiled equipment, such as bedpans. In a temporary setting, such as an ACS, the establishment of a temporary sluice room may not be practicable, and there may not be facilities for emptying buckets, rinsing equipment etc.. The following is suggested:
Allocate a toilet, hand wash basin, not in splash range and restrict access to it for draining buckets and install a macerator for disposal of disposable bedpans. Electrical, water and waste supply points required as per supplier specification.
==== Dedicated patient treatment areas ====
The following dedicated, private spaces per ward for clinical procedures are recommended:
*Counselling and consulting room (can be shared), as shown in the figure below
[[File:Consulting room example layout.png|400px|thumb|center|Consulting room example layout]]
*Minor procedures room, as per the example provided in the figure below 
[[File:Treatment-minor procedures room example layout.png|400px|thumb|center|Treatment / minor procedures room example layout]]

== '''Logistical Services''' ==
=== Communications ===
Electronic communication should be facilitated in all zones of the ACS by the provision of device charging stations, and wifi.
=== Visitors entry point ===
Visitors are strongly discouraged from entering the ACS.
*In paediatric wards, one parent may be accommodated to visit a patient. In such cases, direct access for the visitor should be provided so that the visitor does not need to pass through the general patient area. Appropriate PPE must be donned before entering the patient area and hand washing/sanitising must be done when exiting the area.
*Non-patients who are accompanying suspected patients to the facility for testing or admission must be accommodated in a well-ventilated, spacious waiting area. Signage in such waiting areas must inform visitors about symptoms, hand hygiene and PPE.
*Hand washing/sanitizing facilities should be provided.

=== Staff areas ===
==== Staff change rooms ====
A minimum of 9m² or 4m² for a single person, increasing by one m² for each additional person is required. The clean (street side) and dirty (contaminated facility side) of the change room should be separated by a step-over barrier.

==== Staff rest areas ====
Staff rest areas within the main facility should be provided with access to kitchenette facilities and staff ablutions.
=== '''Staff auxiliary services''' ===
'''Staff on-call:'''Since staff may be required to work long hours or could be required to be on-call, shared, overnight sleeping facilities can be provided for staff on duty, outside the contaminated area, but in close proximity on the patient areas. An example is set out in the diagram below.
[[File:Example of on-call sleeping area for staff.png|center|600px|thumb|Example of overnight sleeping area for staff]]

'''Staff accommodation:''' It is advisable to provide some staff accommodation for off-duty staff who may not have suitable alternatives, for example homes too far away, transport limitations or the requirement not to expose family members to risk. This should be provided in the vicinity of the ACS, but in a physically separated zone. This amenity can be outsourced.

== '''Support Services''' ==
=== Workflow principle ===
[[File:Linen processing cycle.png|none|thumb|Linen processing cycle <ref>IUSS 2014 [https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department]</ref>]]
Progressive workflow from “dirty” (that is contaminated) to “clean” linen is advisable to reduce the risk of exposure to contaminated materials. The workflow diagram below, showing the progression from the dirty linen receiving area, to the cleaning process, to decontamination and drying, and finally sorting and packing, and storage, illustrates this principle.
=== Laboratory ===
[[File:Example of modular laboratory.png|right|thumb|Example of modular laboratory]]
The WHO recommends the following laboratory diagnostic equipment be accommodated:<ref>WHO 2020, [https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items]</ref>.
<nowiki>• Lab screening test kit
• Lab confirmation test kit
• RT-PCR kit
• Extraction kit
• Cartridges for RT-PCR automatic systems
• Swab and Viral transport medium
</nowiki>
Additional accommodation requirements are:
# Reception counter- receiving specimens
# Testing with perspex/ glass screen
# Receiving/Data capture
# Specimen holding
# Toilet - staff
# Blood storage fridge
Can be provided as a modular laboratory unit as shown in the diagram.
=== Pharmacy ===
The purpose of the pharmacy is to provide medicines needed for inpatient treatment and care.
All medical supplies should be stored in a secure, climate-controlled area in close proximity to the patient treatment area. The pharmacy must have dry, lockable, climate-controlled storage of medications. Most pharmaceuticals are labelled with storage temperatures. The pharmacy should have adequate ventilation through an openable window to prevent humidity from building up in the room. Air-conditioning or mechanical ventilation can be provided, if necessary.

Dispensing areas must be well lit. Worktop in space for stock records and administration. Dispensing counters to have perspex or glass screens to serveries. Social distancing implemented at counter, between pharmacists/assistants and between chairs in waiting area.

Can be provided in a mobile unit.

=== Radiology ===
The purpose of radiology services is to provide chest X-Ray services for COVID-19 diagnostics. In general, CT scans, bucky rooms etc. associated with some radiology equipment require specialised infrastructure and therefore is not suitable for ACS. Radiology services can be provided as a mobile floor standing unit, or containerised unit. Alternative technologies such as Lodox and hand-held ultrasound devices are being investigated as potential options and could be confirmed as suitable for use in due course.
=== Laundry services ===
All dirty linen should be handled for bagging or binning inside the patient room/cohort area. The clean linen stock should be stored conveniently close to clinical areas, in a dedicated clean area in the uncontaminated zone. Used linen should be stored in a designated, safe, lockable holding area while awaiting collection. Interim storage areas for soiled linen at the wards is allowable; this may be in dirty linen/ utility room.
Any clean linen for PUI areas should be handled in spaces physically separate from dirty linen of confirmed patient areas. It may be necessary to completely separate PUI and confirmed patient linen streams. Soiled linen and clean linen bags and bins should be dedicated and not mixed.
Full laundry cleaning and drying services may be provided on-site or outsourced. If laundry cleaning and drying services were already rendered on or for the host site before it is repurposed as an ACS, then a suitability and risk assessment should be conducted to ensure that the volumes of laundry generated and infection prevention and control measures are conducive and modifications made as necessary. A new full laundry service may take time and resources to establish, and in general, will not be established at a host site as a temporary solution. Where the site and circumstances advocate for the design of a new laundry or the upgrade of an existing laundry, the IUSS Laundry Services for Hospitals should be applied.
==== Siting and model selection considerations ====
When an existing laundry is being assessed for use or a new one is being planned the following considerations apply:
* Water and power capacity.
* Ease of access to the ACS’s main corridors and internal transport routes.
* The noise factor of the facility and its impact on nearby patient care departments.
For outsourced departments:
* Delivery areas to allow sufficient space to ensure that vehicles can manoeuvre and park easily at the reception and dispatch bays.
* Access to the ACS service roads and public roads.
==== Functional requirements ====
The most basic equipment needed in a laundry includes washing machines, tumble dryers and ironing machines. Equipment requiring steam is not recommended for a temporary facility. The sizing of the laundry, equipment and engineering services can be modified based on the principles provided in the IUSS Laundry and linen.
=== Catering services ===
Kitchenettes, that is, areas for tea, coffee and snacks, mainly for staff, in staff pause areas are discussed elsewhere in this document.
Catering services (for staff and patients) may be provided on- or off-site. If the ACS is to be established with easy access to a suitable, existing, functional kitchen service (e.g. hotel, military or hospital catering) which can meet the additional demand of the ACS, then this should be used. If there is no suitable facility, catering should be outsourced via a suitable off-site supplier. Only in the event that no feasible or suitable, existing facility or local supplier is available, should a new catering service be established at the ACS. Detailed guidance for the sizing, design and layout of catering services can be found in the IUSS Catering Services for Hospitals.
The kitchen (for on-site catering) or preparation area (for off-site catering) should be located with easy access to the point of delivery and storage of food. Adequate food and equipment storage space must be provided.
It is recommended that patient and staff meals, where provided, be supplied in disposable, containers, suitable for incineration, and that these are disposed of as risk waste immediately after use.
Where off-site catering is used, a suitable area for receiving should be provided. Space will be required for sorting meals for distribution and collecting and storing dirty dishes, washing dirty dishes, if necessary, and disposing of left-over food and disposable containers and utensils. The size of the areas required for this will depend on the number of meals delivered.

=== CSSD ===
The primary function of a Central Sterile Supply Department (CSSD) is to provide an efficient, economic, continuous and quality supply of disinfected and sterilised items, when needed, to all patient-care service points in the ACS, and to receive returned contaminated items for cleaning.
CSSD with limited sterilisation capacity (autoclave) but sufficient disinfection capacity (instrument washing). The layout requires a designated clean and dirty areas with a hard barrier between to avoid cross-over of staff and equipment. Work is unidirectional - flows from dirty – to clean - to sterile areas.
This yields three distinct zones:
1. Receiving and cleaning with pass-through windows
# Dirty receiving with Perspex or glass partitioning
# Dirty utility
# Decontamination and cleaning/wash area with throughput instrument washing
# Trolley wash/Park – external
2. Inspection, assembly and packaging with pass-through windows
# A tabletop autoclave
# Instrument washer
# Clean Packing area
3. Sterile processing, storage and distribution. (Separate issuing area from receiving area) with pass-through windows
# Store -linen and consumables
# Sterile pack store
# Issue - Collection hatch with Perspex or glass partitioning
Must also have a secure, separate receiving area for consumables receiving and storage.
An example of a CSSD unit is shown in Figure 21.T

[[File:An example of a small CSSD facility.png|600px|thumb|none|An example of a small CSSD facility<ref>IUSS 2014, https://www.iussonline.co.za/norms-standards/support-services/24-central-sterile-service-department</ref>]]

To be understood: Quality of services, eg. water (including a source of distilled or ionised water for rinsing of bronchoscopes) and electricity, quality of management, if equipment is appropriate for needs and fit for purpose, what is required of the equipment in the near and far future (relocation?), compliance with S.A. National Standards for CSSD, compatibility of equipment and devices, correct chemicals, maintenance of equipment, training of operators. Although the use of disposable breathing circuits and accessories (masks) should be encouraged, the capacity to disinfect these items if disposable is not available must be considered.

The CSSD must be sized to serve the ACS. Considerations are workload and space requirements. CFSA has extensive [https://www.fidssa.co.za/Content/Images/CFSA_SOP_2018.pdf standard operating procedures] for CSSD.

Workload: Number and type of procedures, number of procedure rooms, eg for bronchoscopy, operating hours, available inventory, volume of work and peak times, degree of mechanization, eg. manual or automated instrument washing, amount of product to be stored – chemicals, barrier wrap, chemical indicators, etc., storage and distribution records, quality records – eg. equipment checks, disposal needs.

Space requirements: Space for separation of clean and dirty, allow for unidirectional movement, allow space to manoeuvre trolleys (queue, pack/unload), reduce lifting and carrying heavy items, reduce awkward movements, allow for tidy work areas. Insufficient space will compromise sterility!

Preference should be given to construction materials and finishes which are suitable for frequent cleaning and tolerant to chemicals, including bleach (sodium hypochlorite). Impermeable flooring, non-slip and smooth washable walls are needed. Joints at walls and floors and coving at wall edge, and exposed drains should be avoided. Worktops should be sealed and should be ergonomically suitable.

Ceiling heights below 2.8m may be vulnerable to damage from humidity Where steam and moisture are generated. Noise – insulation of washer-disinfector and steriliser in technical walls will reduce noise. Lighting: Natural light if possible – windows sealed. High luminance if artificial lighting. Open, slatted shelves for sterile store area. Sinks for manual washing: At least two basins, deep (25cm at least) basins, 91 cm from floor, wide and long enough for the biggest instrument tray or container, water ports for flushing of lumens.

The CSSD space allocation and layout should be determine based on what procedures and which medical devices will be required. A typical [[equipment list is provided here]].

=== Maintenance and cleaning ===
Maintenance and cleaning services must be accommodated with offices located away from clinical areas.

=== Mortuary services ===
The National Department of Health has issued guidance on handling of dead bodies and infectious remains<ref>National Department of Health South Africa, 2020 [https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf]</ref>, which should be applied to ACS. While some guidelines have recommend that bodies of persons who have died from COVID-19 should only be held for a very brief period prior to cremation or treatment for burial<ref>Zhejiang University, 2020 [http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm]</ref>, the WHO holds the view (at the time of writing) that there is no evidence of persons becoming infected from exposure to bodies during normal ceremonial and burial activities. However, appropriate PPE should be used when handling such bodies with additional airborne precautions to be taken during autopsies<ref>WHO, 24 March 2020 [https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf]</ref>.

Either body cabinets or a refrigerated room could be used for body storage.
==== Location and layout of mortuary service ====
It is likely that not all alternative care sites will have a mortuary. Those without a mortuary must have a holding room that is located away from general access areas. This holding room must be suitably sized and conditioned. A recommended room size is 3.5 m x 3.4 m<ref>IUSS Adult Inpatient Services, 2014, [https://www.iussonline.co.za/docman/document/clinical-services/65-adult-inpatent-services-gazetted/file]</ref>
A mortuary should be located so that it is easily accessible to mortuary staff and related service providers and visitors without presenting either aesthetic, emotional or ethical problems for unrelated staff, patients or visitors. It should be separate from the general facility, allowing access for the family to view a body without passing through any potentially contaminated area of the facility. The visitors’ entrance should be external and completely separate from other access points.
Appropriate routes should be designated so that bodies are not moved through public-access areas.
==== Sizing of mortuary ====
The layout and size of a mortuary are largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.
==== Services ====
The following services are required in a mortuary:
* Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.
* Sluicing facilities are to be provided in both the body-preparation and autopsy areas if they are not a common area.
* Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush-fitted stainless steel grids.
* No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.
* The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.
* Anti-backflow devices should be fitted to the water-supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.
* Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.
==== Finishes ====
Wall and floor finishes should be impervious to liquids and easily cleanable.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Environmental Controls''' ==

== '''General Indoor Environment Conditions''' ==

Existing environmental control systems should be modified to suit requirements in the facility. The following issues should be considered:
* Systems should be set to maximise the introduction of fresh air and maintain the pressure regime (see ventilation).
* The following internal temperature range should be maintained 19 - 24oC.
* Cooling systems should be able to cater for projected internal heat gains from people, lighting and equipment. Indicative heat gains in treatment areas are 8W/m2 from people, 15W/m2 from lighting and 3 W/m2 equipment and in critical care areas 16W/m2 from people, 15W/m2 from lighting and 60W/m2 equipment.
*As heat gain can vary widely between items of equipment, heat gain and utilisation rates for equipment should be obtained from the manufacturer to establish this more accurately.

=== Solid waste from ACS ===
According to the National Department of Health COVID-19 Environmental Health Guidelines
“All solid waste from the facility should be regarded as potentially infectious material and therefore appropriate precautions should be taken". The management of healthcare risk waste (HCRW) should follow the correct identification segregation, storage and disposal processes as indicated in SANS 10248-1.

* HCRW is segregated at the point of generation and shall be containerized to minimize the risk of contamination.
* Waste generated from patients in isolation or quarantine in a designated facility health facility is treated as health care risk waste (HCRW) as per SANS 10248-1-2008.
* The HCRW is properly packaged in a sealed, leak and puncture-proof containers/ boxes.
* The HCRW is labelled with the biohazard symbol/ sign and marked “Corona virus or COVID-19”.
* The HCRW is stored separately from other waste generated.
* The collection, transportation, treatment and disposal is provided by only an appointed/ appropriate contractor/ service provider, however, ensure that waste is safely stored until the health care waste management company can pick it up and that the company knows and acknowledges that waste was generated by suspected or confirmed COVID-19.
* The waste management company collecting must ensure that and treated and disposal is conducted at license waste treatment/ disposal facilities .
* All personnel or staff in contact with patients must be geared with appreciate personal protective equipment (PPE’s) at all times to prevent exposure or risk to health.
* Monitoring should be done at such facilities.
* All, bags, bins and boxes must be adequately sealed, as not to leak any fluids, and must be wiped down with 0.05% chlorine solution

Measures developed should consider the following.
* Develop a waste management plan following national guidelines and best practice standards for the disposal of medical waste (WHO, 2020).
* Establish procedures with medical waste service providers to regularly pick up the waste and dispose of this safely.
* Provision should be made for 5kg of solid waste per bed per day and this should be monitored and supplemented where it appears this may be inadequate.
* Ensure that access to waste is secure and controlled, for instance, by using lockable waste 1000l containers kept in a location that can only be accessed by health facility and nominated service delivery staff.
* Vermin control programs must be implemented throughout the site with HCRW collection points prioritised
* Provision for safe cleaning and disinfection of reusable containers should be provided. Cardboard, single-use HCRW boxes are removed from site and incinerated.
* Waste must not be allowed to accumulate or be stored inappropriate or unsecured containers.

== '''Engineering Services''' ==
Engineering services include patient services, ventilation, electrical power, water, medical gases, oxygen, compressed air, vacuum, lighting, and fire safety that support the needs of the patients and medical staff under normal and emergency situations. Good practice standards are provided in:
* IUSS Building Engineering Services<ref name = "IUSSBES">IUSS 2017, [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file]</ref>
* NHS Nightingale Instruction Manual<ref name="BDP2020">BDP 2020, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf]</ref>.
The guidance below draws on these and other manuals and standards. 

=== Building ventilation ===
==== Mechanical ventilation ====
While SARS-CoV-2 RNA has been detected in aerosol form, in experimental mechanical aerosolization studies, it is primarily spread through droplet and contact spread and the potential for airborne transmission is thought to be low.
However, the following advice is provided by ASHRAE regarding HVAC systems in general spaces (not specific to healthcare):
Effective high levels of ventilation must be achieved in the facility. Existing ventilation systems should be tailored to suit internal layouts and requirements and the following measures should be taken.
* Mechanical systems should be set to maximise fresh air supply to the facility. There should be no recirculated air without HEPA filtration or other validated decontamination processes.
* A pressure regime should be established, as shown in figure 2, to 'push' air from clean areas, to dirty areas and then out of the building.
* A clean air supply of over 10 L/s per person should be targeted for odour control.
* Fresh air supply shall not be located near patient beds to avoid drafts in winter.
* Extraction points can be located near patient beds in isolation wards or at a high level in long-stay wards. Short-circuiting of air between high-level supply and extraction is a performance risk in winter.
* Noise from ventilation systems and fans shall be below 45 dBA
* Protected lobbies, internal partitions, door arrangements, fans and extracts should be used to maintain the pressure regime and airflow as indicated in the diagram below.
 

[[File:Ventilation in temporary facilities.png|600px|thumb|none|Ventilation in temporary facilities<ref name="BDP2020"/>]]

==== Natural ventilation ====
The airflow direction between naturally ventilated zones may fluctuate according to the wind direction. This is not of concern within and between contaminated zones where occupants are either protected with mandatory PPE or confirmed to be infected with disease strains similar enough so as not be able to reinfect others. Where levels of occupant susceptibility to an airborne disease is significantly different, the less susceptible areas (such as PUI areas and uncontaminated areas) shall be protected from the naturally ventilated and contaminated areas by mechanical ventilation systems with a capacity sufficient to overcome the expected natural ventilation pressure fluctuations (typically 5-15Pa). Where such mechanical ventilation systems are not feasible or expected wind pressure is too great, zone adjacently must be avoided.

===Ultraviolet germicidal Irradiation===
The application of Ultraviolet Germicidal Irradiation (UVGI) for room air disinfection is well understood and is proven to be effective in the disinfection of microorganisms including M. tuberculosis (TB) in air. UVGI should, therefore, be considered as a valid element in indoor airborne infection control strategy for high volume settings. Studies have demonstrated the importance of good vertical air mixing in the room, and the safety of UVGI application. In areas where UVGI is indicated, the design and development of UVGI systems should be in accordance with the [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]<ref>van Reenen et al,2019 [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]</ref>

=== Electrical power ===
Sufficient and reliable power must be available at the facility for envisaged medical equipment, medical gases, lighting and building ventilation equipment. Power installations for the temporary facility can be divided into three zones as indicated below. These are existing services, the temporary service zone and services in each bay.
The following should be considered by competent engineering professionals.

=== Existing services ===
*Capacity: Evaluate whether sufficient power to accommodate envisaged medical equipment, additional lighting and heating, building ventilation and air conditioning can be provided. If existing capacity is insufficient, investigate if it is possible to route additional power from additional locations/transformers around the site or from adjacent sites.
* Safety: The existing electrical distribution network must be able to supply the required equipment load. If this is insufficient/appears unreliable, identify how this can be supported.
* Resilience: Evaluate back-up power and a UPS capacity against essential services demand. If existing capacity is not sufficient, source and establish temporary service capacity.

=== Temporary service zones ===
*Identify locations for temporary service zones where equipment can be located.
*Ensure that equipment and maintenance access is safe and easy.
*Ensure that all distribution boards, circuit breakers and cables are clearly labelled.
=== Services in each bay ===
*Provide pre-wired power strips/trunking as per bay requirements.
*Check that these include sufficient electrical outlets and service points for envisaged equipment.
*Ensure that trunking will carry required equipment loadings. The IUSS Building Engineering Services Guide can be used to check requirements<ref name = "IUSSBES"/>.

[[File:Layout_of_power_in_a_temporary_installation.png|600px|thumb|none|Layout of power in a temporary installation <ref name="BDP2020"/>]]
----

=== Water ===
Water points are needed for handwashing, showers and cleaning. The following issues need to be taken into account.
==== Supply ====
Onsite cold water storage, dedicated to the domestic water requirements of the facility, should be provided. A minimum usable volume of 500 litres per bed should be available.
Hot water storage and consumption should be confirmed by an engineer, as follows:
*Storage 25 L per bed.
*Consumption 180 L/bed.day W/O laundry; 250L /bed. day W laundry.

==== Handwashing ====
See infection control for clinical wash-hand basins
==== Showers ====
Showers for staff coming off shift should be available. Staff flow routes exiting contaminated treatment areas should pass through gowning and shower areas.
----

=== Medical gases, oxygen and vacuum (suction) ===
Medical gases, oxygen and vacuum services will be required in the facility. Mobile gas supply requires piping between supply and patient and clutter floor space. Preferably used fixed installations for patient rooms/cubicles, if possible.

System capacity and point of use pressures and consumption rates are to be ensured at all points. WHO provides technical guidance on [https://www.who.int/publications-detail/oxygen-sources-and-distribution-for-covid-19-treatment-centres oxygen sources and distribution]. 
[[File:Medical gas service layout.png|6oopx|thumb|Medical gas service layout<ref name="BDP2020"/>]]
The following points should also be taken into account.
* For centrally supplied medical gas and vacuum services, system resilience and availability must be ensured.
* Compressors, tanks, accumulators, VIEs, headers and controllers must be secured from uncontrolled access.
* Where possible, gas piping should be reticulated below floors or in ceilings to ensure protection from tampering, damage and ease of access.
* Where reticulation is within open areas, high-level reticulation with point-of-use droppers is advised. Low-level reticulation within rooms is to be avoided.
* Flexible piping can be used, ensuring it does not present a contamination or fire risk and should comply with local regulations. Special care should be taken with flexible O2 piping, keeping it to a minimum.
* Vacuum piping may be contaminated, where point-of-use filtration and collection systems fail. Precautions should be taken when demounting or disconnecting temporary vacuum lines.
* Ensure that oxygen pipelines are designed to provide sufficient flow to all oxygen points in the facility. In terms of utilities, oxygen and medical air would be required. A temporary vacuum point can be provided by mobile medical vacuum units distributed throughout the unit.
* Mobile medical air supplies should be considered where reaching piped specifications are not feasible. Where flexible hoses are used for oxygen and medical air special precautions need to be taken. Flexible oxygen piping must be chemically safe for O2 use. Where perishable flexible piping is used for medical air, terminal filtration at the point-of-use may be required at point-of-use. Especially for long-term use.
* Electrical and gas services can be reticulated against pipe racks or boards fixed to the bed-heads for head to head bed arrangements.
* Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.
* Gas service outlets to be labelled and colour-coded with 3mm lettering.
* SANS 7396-1 should be used to specify the requirements from design to commissioning of medical gas and vacuum systems.
* Medical gas and vacuum pipelines shall be marked per SANS 7396-1 and ISO 5359, as applicable.
* Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.
* SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.
* Plain-ended copper tubing for low-pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.
* Laboratory gas taps and valves shall be marked as described in SANS 10140-4.

=== Lighting ===
Existing lighting systems may need to be modified to suit the clinical requirements in the facility. High bay lighting presents inadequate colour rendering quality for the accurate detection or easy diagnosis of certain clinical conditions. This needs to be evaluated in the selection of supplementary lighting systems.
*Lighting levels should be provided in line with the indoor lighting levels recommended in the Table 6 of IUSS Building Engineering Services .
*Mobile task lighting systems may be adopted in the serious and critical stay wards to supplement incorrect lighting quality.
*Emergency lighting and illuminated emergency egress signage should be linked to the back-up power system.
*External security lighting in external parking areas and spaces around the building should be enhanced to ensure the security of medical staff who need to change shifts at night.

=== Fire safety ===
A functional fire alarm system should be available to support the patient care setting. Fire is a very real threat due to the possibility of an oxygen-enriched atmosphere developing so ventilation is crucial.
The use of temporary facilities for medical care should note the following fire risks (NHS, 2020):
*Patients may have a very high dependency.
*Areas are not specifically designed for patients and do not meet guidance on fire compartmentation and progressive horizontal evacuation.
*Large numbers of patients supplied with oxygen up to 10 litres per minute.
*Possibility of oxygen concentrations exceeding those generally found in the atmosphere- less risk if effective ventilation or large volume i.e. high ceilings.
* Possibility of storage, in excess of 40 litres, of alcohol-based chemicals (such as hand-rub), necessitating a flammables cabinet on site.
*Staff who may not normally work together .
*Staff who may not be familiar with the area.
*Staff not trained in fire safety, progressive horizontal evacuation or oxygen isolation for the specific area.
These factors should be taken into account in fire risk assessments which should then address significant findings in an action plan. Fire assessments should be undertaken by a qualified person and shared with operations and building management staff within the facility. Measures developed should include:
*An automatic fire detection system
*An emergency egress plans are prepared that include patients who have a very high dependency.
*Signage, notices and lighting are installed and are working effectively.
*Management processes are in place to minimise the risk of fire from ignition sources, fuels and oxygen.
*Staff are trained and a fire safety guide sheet for staff is developed and issued.
*Emergency egress routes are kept clear.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Additional Resources''' ==
=== [[Directory of Service Providers|A Directory of Service Providers can be viewed here]] ===

=='''References'''==
<references />

[[Category:COVID-19| ]]
[[Category:Alternate Care Sites|Alternate Care Sites]]

----
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19|(Return to Top)]] 
----

Infrastructure Guidance for COVID-19/Alternate Care Sites

2020-05-08T08:36:05Z

Peta: /* General transmission mitigation */

[[Infrastructure Guidance for COVID-19|Return to Infrastructure Guidance for COVID-19]] 

== '''Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19'''==

This guidance work was initiated under the project titled: 
''Reducing Nosocomial and Community-Acquired Tuberculosis by Strengthening the Capacity of the South African Department of Health to Improve Implementation of Infection Control and Waste Management at All Levels of the Health System Under the President's Emergency Plan for AIDS Relief (PEPFAR)'' 

== '''Purpose and Approach''' ==
The global pandemic of COVID-19 caused by the coronavirus, SARS-CoV-2 is likely to result in a surge in need for medical care for Severe Acute Respiratory Syndrome (SARS) in South Africa. Considering the course of the pandemic in other countries, it is anticipated that South African hospitals will not have sufficient capacity to cope with the surge of persons requiring medical attention and that surge capacity via alternate care sites (ACS) will need to be established.
Surge capacity, contemplated here is not the frequent emergency department overcrowding experienced by healthcare facilities (e.g. Friday/Saturday night emergencies) or local casualty emergency that might overcrowd nearby facilities and have little to no impact on the overall healthcare delivery system. It is when a catastrophic event occurs and the affected population seek medical care from existing local healthcare facilities, causing healthcare infrastructure to become exhausted due to excess in demand. During a healthcare surge, the standard of care will shift from focusing on patient-based outcomes to population-based outcomes, and providers should anticipate “a shift to providing care and allocating scarce equipment, supplies and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals.”<ref>[https://asprtracie.hhs.gov/technical-resources/resource/491/altered-standards-of-care-in-mass-casualty-events Health Systems Research Inc., 2005]</ref> 

Surge capacity can be temporarily established in non-traditional environments, such as hotels, exhibition halls, community halls, and as field hospitals, on open spaces. 

In the context of this document, a quarantine site is a facility for patients who do not require continuous professional medical care, while an ACS is defined as a temporary facility that can provide continuous medical care for SARS. This document provides principles and considerations, high-level guidance for minimum requirements and examples for ACS. 

While an extensive set of health facility guidelines does exist<ref>[https://www.iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-servi IUSS Building Engineering Services (2017)]</ref>, these are applicable for conventional facilities and thus include services and guidelines that are not necessarily relevant to the treatment of a novel, highly infectious pathogen, with pandemic effects. Moreover, these do not provide well for the rapid and temporary establishment of facilities. 

In order to formulate high-level guidance, [[as invited by Business for South Africa]], the team reached out to professional industry bodies for inputs, in particular the South African Institute for Architects (SAIA), The Gauteng Institute for Architects (GiFA) [https://www.gifa.org.za/ Gauteng Institute for Architecture] and the [http://www.safhe.co.za/ South African Federation of Hospital Engineering (SAFHE)], by inviting input via a 36-hour research charrette. Relevant historical and contemporary literature was consulted, precedents identified and critically reviewed. An interaction with the team at Wuhan responsible for makeshift hospitals and emergency infectious diseases hospitals, Central-South Architectural Design Institute, was arranged with assistance of the Chinese Embassy. Material from the [[Infrastructure Unit System Support|Infrastructure Unit System Support (IUSS)]], international literature and guidance and input gathered from the broader architectural, engineering and healthcare professional communities was synthesised and moderated by the CSIR team. The draft was reviewed by an expert review panel. 
=== Acknowledgement of contribution ===
The contributions to the initial version of this were gratefully received. [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Acknowledgements|A list of these contributors can be viewed here.]]. 
New contributions are eagerly encouraged along with debate and discussion on the [[Talk:Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites|'''discussion forum.''']] tab above.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Scope and Assumptions''' ==
ACSs as discussed in this document are dedicated, temporary facilities for triage, testing, diagnosis, further referral and treatment of persons:
*suspected of having contracted SARS-CoV-2, (persons under investigation (PUIs)), who are symptomatic and/or are awaiting results,
*or are confirmed to be infected.
ACS will accommodate a variety of clinical, logistical, support and auxiliary services associated with the render of care. ACS will currently not be licensed to provide healthcare services. Since the ACS will operate in a non-healthcare facility, it cannot fully replace a hospital setting and its prime objective is to manage the patient load until the local healthcare system can meet demands. 

=== Exclusions ===
Quarantine facilities are accommodation facilities where a member of the community can remain for the duration of their isolation period. This is typically temporary housing for a cohort of people who do not need intensive medical attention but who cannot stay at home. Patients can take care of themselves and need limited monitoring by medical staff. Quarantine: Containing presumptive-case patients from each other and the general population.
Quarantine facilities – that is for asymptomatic persons who are in the community in self- or imposed isolation, but not displaying symptoms, or who are symptomatic, but are able to safely recover without clinical intervention and do not need continuous medical observation are not considered in this document.

=== Service regime ===
The following assumptions are made with respect to services under consideration.
* Temporary - limited to the part of the pandemic when the “conventional” hospital platform cannot meet demand. To be dismantled, thereafter.
* Uncomplicated, dedicated COVID-19 care is to be prioritised for ACS.
* Patients with comorbidities, paediatrics will be prioritised for conventional facilities, and only accommodated in ACS as a matter of last resort.
* 24 hour, 7 days a week operations. 

=== Assumed mechanism of transmission ===
Transmission of SARS-CoV-2 is understood to be from person to person firstly by [https://en.wikipedia.org/wiki/Transmission_(medicine)#Droplet_infection droplet] transmission, then by the [https://en.wikipedia.org/wiki/Transmission_(medicine)#Direct_contact contact] route and finally via airborne [https://en.wikipedia.org/wiki/Transmission_(medicine)#Airborne_airborne transmission] during or following mechanical aerosolisation. Water transmission risks are minor, occurring in special [https://en.wikipedia.org/wiki/Transmission_(medicine)#Fecal%E2%80%93oral Fecal-oral] circumstances. Reclassification of transmission mechanisms may nullify some of the approaches presented in this guidance. 

=== A call for strategic coordination ===
This document focusses on infrastructure requirements. These provisions are meaningless without staffing, equipping and resourcing. Whilst staffing, equipping and resourcing are not the focus of this document, these are likely to emerge as key constraining features. Resource constraints are likely to become acute during this pandemic. Doctors and nurses are already in critical short supply in South Africa and internationally, and are themselves susceptible to COVID-19 infection. Equipment and consumables are in short supply with heightened global demand, reduced manufacturing capacity and limits in trade flows. This necessitates strategic coordination, proactive planning, options appraisal and prioritisation. 

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Status Quo''' ==
=== Rationale and transmission status ===
According to the [https://en.wikipedia.org/wiki/World_Health_Organization World Health Organisation] (WHO), based on the largest cohort of COVID-19 patients, about 40% of patients with COVID-19 may have mild disease, where treatment is mostly symptomatic and does not require inpatient care. About 40% of patients have moderate disease that may require inpatient care; 15% of patients will have severe disease that requires oxygen therapy or other inpatient interventions, and about 5% have critical disease that requires the patient to receive mechanical ventilation. However, the evolution of the outbreak in some countries has shown a higher proportion of severe and critical cases and the need to rapidly increase surge capacity to prevent rapid exhaustion of biomedical supplies and staff. In some countries, doubling rates of cases every three days has been observed<ref>WHO-2019-nCoV-HCF_operations-2020, [https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf]</ref> 

South Africa has a high burden of disease, with a high prevalence of [https://en.wikipedia.org/wiki/HIV/AIDS_in_South_Africa HIV and TB]. Although evidence is yet to emerge of the effect of SARS-CoV-2 on a population with these pre-existing conditions, there is reason to proceed with caution<ref>The Conversation 2020, https://theconversation.com/tb-hiv-and-COVID-19-urgent-questions-as-three-epidemics-collide-134554</ref>. There is a potential direct and indirect benefit of ACS to people living with HIV and TB, as well as to general public health and the health system preservation. 

With the travel lockdown in place, and continued transmission, it appears that South Africa is on the cusp between cluster transmission and community transmission according to WHO’s classification, shown in the [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites#Key_clinical_and_infection_control_activities_for_different_transmission_scenarios_.5B3.5D|table below]], indicating that preparation should include temporary hospital facilities and mass critical care.

==== Key clinical and infection control activities for different transmission scenarios <ref>WHO 2020, [https://apps.who.int/iris/handle/10665/331492 https://apps.who.int/iris/handle/10665/331492]</ref> ====
{| class="wikitable"
|-
! !! '''No Case''' !! '''Sporadic Case''' !! '''Clusters of Cases''' !! '''Community Transmission'''
|-
| Faculty Space, Including for Transmission|| Usual Space. Enhanced Screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards). || More patient care areas re-purposed for COVID-19 within the health system, especially for severe cases || Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Staff|| Usual space. Enhanced screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards)||More patient care areas repurposed for COVID-19 within the health system, especially for severe cases||Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Supplies||
*On-hand supplies. Equip wards for COVID-19 treatment.
*Identify essential equipment and supplies, including oxygen.
*Prepare expanded local supply chain
||
*Expanded inventory of supplies with detailed protocols for use.
*Activate expanded local supply chain.
*Prepare national supply chain.
||
*Conservation, adaptation, selected re-use when safe.
*Activate contingency planning and procurement for essential equipment and supplies.
*National supply chain.
*Prepare expanded supply chain at the global level
||
*Activate contingency planning should critical equipment be in short supply.
*Determine allocation of lifesaving resources for HCWs and patients.
*Activate expanded global supply chain
|-
| Standard of Care|| Usual care with enhanced awareness and recognition of immediate needs for first COVID-19 patients|| Usual care and treatment for all patients, including those with COVID-19||Identify context-relevant core services. Shift service delivery platforms. Consider reduction in elective patient encounters, including elective surgical procedures.|| Mass critical care (e.g. open ICU for cohorted patients).
|-
| Care areas expansion|| No requirements for expansion|| Designate 10 beds per suspected COVID-19 case|| Expand COVID-19 patient care areas by a factor of 35 ||Expand COVID-19 patient care areas by a factor of 58
|}

=== Quantification of need ===
At this time there are various parallel initiatives aimed at forecasting the South African epidemic, quantifying the projected need for facilities, and a shortfall in existing capacity. At this time, there is no consensus on this. This section will be updated as further data becomes available.
ACS will prioritise mild to moderately affected COVID-19 patients where basic, targeted medical care will be provided. Should patients’ needs evolve, requiring escalation of care, then the transfer of patients from ACS sites to conventional sites of care will be needed as a matter of course, bringing with it logistical challenges and risks. In the event that the conventional hospital platform is unable to cope, ACS will have pressure to provide care for severe and critical patients, and finally for patients with comorbidity and special requirements, such as paediatrics, persons living with HIV (PLHIV), TB patients and pregnant women. The following pragmatic approach, aligned with the WHO recommended strategic approach, is suggested.
*ACS should preferably be identified with space for expansion.
*The set-up should be done so that levels of care can be upgraded to higher levels of uncomplicated care.
*A secondary upgrade for more diverse package of care may become necessary.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Strategic Approach''' ==
According to WHO, clinical interventions must be put into place immediately and then scaled up according to the epidemiologic profile.
[[File:COVID-19 Resource allocation.png|none|thumb|600px|right|WHO Strategic approach to clinical care]] 
Under this declared state of disaster, the clinical care strategy which cannot be accommodated within existing facilities, can, on a temporary basis be hosted in ACS:
*Within and around existing healthcare facilities, via reconfiguration and/or augmentation.
*In existing non-healthcare buildings suitable for repurposing, such as universities, hotels and conference centres, warehouses, gyms, hostels etc.
*On open fields, including paved parking areas with rapidly constructed, dismountable structures, such as modular tented structures or using rapid modular construction techniques. 

ACS will provide isolation, general (non-acute) care for patients with mild to moderate symptoms and as required, acute care for patients with severe symptoms. Containing confirmed-case patients from general population. Confirmed-case patients can be housed together en masse, while presumptive-case patients must be individually quarantined.
As shown in the WHO Strategic approach to clinical care, the WHO recommends a range of services to meet patient need (''Citation needed''). General (non-acute) care ACS model is designed for minimal acuity patients requiring minimal activities of daily living support (e.g. COVID-positive with minimal symptoms or require <2L of oxygen). Acute care ACS model is designed for higher acuity patients requiring closer monitoring or respiratory support (e.g. COVID-positive with pneumonia or respiratory distress requiring ventilator support). Paediatric patients are to be accommodated in separate wards, where strictly controlled visitation may be allowed. 
As a preliminary estimate, the following ratios of service is proposed:
[[File:COVID Ratios of Service.png|none|thumb|600px|center|COVID Ratios of Service]]

{| class="wikitable"
|-
! '''Case severity, risk factors<ref group="Notes"> Test suspect COVID-19 cases according to diagnostic strategy</ref><ref group="Note"> Known risk factors for severe COVID-19: age over 60 years, hypertension, diabetes, cardiovascular disease, chronic respiratory disease, immunocompromising conditions.</ref>''' !! '''Recommendations'''
|-
|Mild || Patient should be instructed to self-isolate and contact COVID-19 information line for advice on testing
and referral.
|-
|Moderate, with no risk factors ||Test suspected COVID-19 cases according to diagnostic strategy. Isolation/ cohorting in:
* Health facilities, if resources allow;
* Community facilities (e.g. stadiums, gymnasiums, hotels) with access to rapid health advice
(i.e. adjacent COVID-19 designated health post/EMT-type 1, telemedicine)
*Self-isolation at home according to National guidance
|-
| Moderate, with risk factors || Patient should be instructed to self-isolate and call COVID-19 hotline for emergency referral as soon as possible
|-
|Severe || Hospitalization for isolation (or cohorting) and inpatient treatment.
|-
|Critical|| Hospitalization for isolation (or cohorting) and inpatient treatment.
|}

=== Notes and References: ===

<references group = "Note" />
<references />

== '''Typology Dictates (Case Studies)''' ==
[[File:NHS Nightingale Hospital London.png|thumb|NHS Nightingale Hospital London <ref name="NHS Nightingale Hospital London">Coronavirus: Building NHS Nightingale Hospital London, 2020 [https://www.bbc.com/news/in-pictures-52092253 https://www.bbc.com/news]</ref>, ]]
To meet the requirements set out in this guidance, prospective “host” sites should be carefully evaluated. The type of “host” site selected will strongly influence or dictate the choice of ACS service model.

No site is likely to meet all requirements and recommendations set out in this document. Adaptations and compromises will be necessary. Services should be provided on site where it is pragmatic to do so, for example where similar services are provided. Outsourcing can also be practical/feasible for some services, such as laboratory services, catering and laundry, provided suitable logistical arrangements can be made.

Some typological responses and service models are set out in precedent examples, shown below. The examples demonstrate that a variety of host settings are workable, provided that the appropriate utility can be contrived. Other than in metroplitan areas, co-location of ACS on the premises of, or adjacent to existing halthcare facilities will often be preferable because this is where intensivists and specialist clinical staffing will be available, and support services may be well established. Nevertheless, augmenting capacity at existing facilities should take into account current workloads and capacity to ensure that the COVID-19 surge disrupts normal service provision as little as possible, including continuity of care for patients with chronic conditions and TB and HIV patients. 

*'''[[Infrastructure Guidance for COVID-19/Alternate Care Sites/Case Studies|SARS ACS Precedents and Case Studies can be found here]] '''

=== Notes and References ===
<references />

== '''ACS Infrastructure Planning''' ==

=== '''Establishing a team''' ===
A planning team should be formalised to establish the minimum planning and operational requirements for the ACS and to liaise with the local community. The team should include individuals with expertise in the following areas (ideally with knowledge of healthcare delivery under emergency conditions):
*Disaster response / emergency management coordination,
*Clinical care and staffing,
*Infection Prevention and Control practitioners must be involved in all stages of planning, commissioning, in-use, and decommissioning of the facility
*Facility set-up, operations and management,
*Security,
*Transport (patient, staff),
*Engineering and project management,
*Procurement and coordination of supplies, equipment and pharmaceuticals, and
*Community liaison to ensure that concerns of the adjacent population on understood an addressed.
It is important to ensure compliance with health, safety and building regulations, by ensuring the involvement of relevant local authorities. Stakeholder engagement should be formally documented. Concerns and grievances should be systematically addressed.

=== '''Structural integrity and operational responsibility''' ===

'''Structural modifications:''' ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered. 

'''Competent person:''' All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed. 

'''Asset responsibility:''' Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented. 

'''Integrity and responsibility'''

'''Structural modifications''': ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered.

'''Competent person''': All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed.

'''Asset responsibility''': Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented.

'''Decommissioning''': Decommissioning of the facility shall be assigned to the competent person discussed above. All residual structures upon decommissioning shall comply with the National Building Regulations. Upon decommissioning, removal of equipment shall be the responsibility of the owner. An infection prevention and control practitioner should be engaged in the decommissioning phase to oversee terminal cleaning and disinfection of equipment and premises.

'''Closure''': Once all patients can be safely discharged or transported back to existing facilities for continued care and there are no ongoing healthcare surge capacity needs, the ACS can be closed. Shut down of an ACS will require decommissioning, identification of new homes or storage for equipment, and termination of ongoing contracts or arrangements. Shut down should be expedited so that the facility can quickly be returned to the control of the existing owners and returned to its usual function.

Action checklist items for ACS closure should include, but not be limited to, the following:
*conduct a site walk-through with the facility owner when shutdown activities are completed to ensure that terminal cleaning and disinfection of supplies and premises, removal of equipment and supplies, and other surge closure activities have been completed to the owner’s satisfaction.
*perform medical records storage procedures.

== '''Site Selection''' ==
When selecting a site, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital can be utilised to determine whether the site is suitable for a 100, 1000 or 2000 bed facility, as required. The following indicative minimum site sizes are needed:
*100 Bed ACS/ hospital conversion, requires ± 4 300 m2
*1000 Bed ACS/ hospital conversion, requires ± 17 600 m2
Evaluation should be done by examining plans (if available), satellite images, drone images, scans and by physical inspection (walkabout). A comprehensive photographic survey should be undertaken and retained for record purposes on the site inspection. This will serve as an audit record and may assist in returning the site to its original function on ACS decommissioning and closure. When scrutinising documents and conducting site inspections to confirm the suitability of a site to host an ACS, the following criteria should be taken into account.
=== Criteria ===
*Affordability (costs, including operational costs known and budget identified),
*Sufficient physical space and capacity to house the immediate need, with the potential to accommodate physical space requirements. For example, open site should not be sloping,
*Legal rights and encumbrances, including renewal opportunity,
*Good access to highway and main roads,
*Well secured perimeter and limited controlled access points,
*Proximity to other hospitals and care sites,
*Accessibility for key staff and public transport,
*Good vehicular access around the site to set up temporary equipment such as back-up generators,
*Free from clear and present danger,
*Outside attenuation zones, floodplains,
*Outside high wind zones,
*Structure in good repair,
*Effective onsite facilities management team who understand how systems work,
*Potential for expansion, if required,
*Access to sufficient capacity for
**potable water,
**adequate sewage,
**telephone,
**internet access with sufficient bandwidth,
**electricity,
*A zone for cleaning, disinfection, and decontamination of equipment at least 15 metres away from occupied areas with access to water, a hard impervious surface and drying areas in the sun, with runoff discharge into the sewer and not into marine ecosystems or the environment. Include area for cleaning and storage of cleaning equipment.
*Likelihood of acceptance of hosting an ACS by the adjacent and local community

=== Desirable ===
*Durable, cleanable surfaces,
*Large open spaces that can be converted to accommodate temporary structures,
*Good ventilation,
*On-site kitchen and laundry,
*Housekeeping staff (chemical and equipment storage, lockers, rest facility, administration office),
*Space conducive for staff respite area and locker rooms,
*Amenities with universal access,
*Fire protection safety and equipment,
*Elevator access for patients if the building has more than one floor,
*Capacity for expansion, and
*Accessible to at least two roadways to provide continued access in the event that one roadway becomes blocked on inaccessible.

== '''Infection Prevention and Control''' ==
General guidance for COVID-19 [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|Infection Prevention and Control]] can be accessed [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|here]] 

Infection prevention and control in the context of COVID-19 should respond to transmission routes of primary concern for the pathogen of interest (droplet and contact transmission, and management of risk waste) as well as infection risk of a general nature (water and sewerage, airborne transmission – under high TB/HIV burden, and general waste).
In addition to satisfying [https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html standard precautions for all patient care], transmission-based precautions should focus on three pillars: exposure reduction by spatial configuration, operational strategies, and personal protection.
=== Transmission-based precautions ===
'''Droplet and contact spread''': Transmission of SARS-CoV-2 virus occurs via droplet and contact spread. The virus has been shown to persist on surfaces for extended periods of time and is known to be efficient at infecting people. 

'''Medical waste and linen:''' As SARS-CoV-02 is carried in body fluids and faecal matter, disposal of contaminated items (tissues) and cleaning regimes (spaces, garments, linen) should be accommodated carefully in the workflow design and infrastructure provision. A site-specific waste management plan should be formulated in accordance with a site-specific waste management plan with reference to SANS 10248. 

'''Airborne transmission:''' Under exceptional circumstances, the risk of airborne transmission arises for SARS-CoV-2, as detailed below.
{| class="wikitable"
|-
!Airborne Transmission Risk Factors
|-
|
As SARS-CoV-2 is not considered airborne, respiratory protection against airborne transmission is not considered necessary, except where aerosolisation of particles may be a risk.
According to the CDC
*tracheal intubation,
*non-invasive ventilation,
*tracheotomy,
*cardiopulmonary resuscitation, or
*manual ventilation before intubation and bronchoscopy.
According to doctors in the field also when performing
*COVID-19 diagnostic sampling as patients can be induced to cough and sneeze.
*Suspected or confirmed comorbidity of TB is not an additional risk where correct COVID-19 PPE is applied.

|}
South Africa has a high prevalence of TB and HIV, and therefore, although the risk of COVID-19 transmission via the airborne route is not paramount, there is a high likelihood that undiagnosed TB infectious patients may present at the ACS for treatment. TB triage may be challenging in the ACS as there are symptoms in common (coughing) with COVID-19. This country-specific risk is taken into account in this guidance

=== Additional precautions ===
'''Water and sewerage contamination:''' The International Water Association [[Infrastructure Guidance for COVID-19/Alternate Care Sites/COVID-19 A Water Professionals Perspective|concluded]] that water and sewerage contamination is not considered to be a key risk factor for COVID-19. The panel expressed concern for “how waste and specifically wastewater (medical) would be handled by places (e.g., hostels, hotels) that are used to serve as interim COVID-19 quarantine or testing facilities or accommodation ([ACS]. These are places other than hospitals that are used in the interim for such purposes and do not usually handle wastewater from medical settings. Such facilities should be monitored carefully.” 

== '''Spatial strategies for infection prevention and control''' ==

=== Restricted access and zone control ===
The site will be arranged to establish clear zoning, with a clear restricted zone protocol and access protection. Zones should be deemed to be "contaminated" or "uncontaminated" with clear transition areas between them.

; Contaminated zones
: (also known as "dirty areas") are areas occupied by COVID-19 infected persons, PUIs, equipment, materials and supplies which have come into contact with such persons without yet undergoing a decontamination procedure. These areas will include patient ward areas and ablutions, patient admissions (including ambulance drop-off) and the associated clinical areas. Staff rest and dining facilities should be outside the contaminated zone. Limited stock for immediate use should be kept in the contaminated zone. Layout designs should consolidate contaminated zones as far as reasonable, and avoid uncontaminated zones as islands in contaminated zones.

; Uncontaminated zones
: (also known as "clean areas") are areas not generally occupied by PUIs or confirmed COVID-19 infected persons. Equipment, materials and supplies in these areas have not yet come into contact with contaminated zones or have undergone a decontamination procedure. These will include clinical management planning rooms, stock rooms, bulk stores, pharmacy, laboratory areas, kitchen and laundry.

; Transition zones
: (also known as intermediate zone) are the spaces through which transfer of people and goods from uncontaminated to decontaminated zones, and vice versa, occur. Materials from the contaminated zone should be decontaminated or contained in the transition zone. The transfer of goods and persons should be highly ritualised and, as far as possible, traffic across transition zones should be minimised. Transition areas should be strategically located to serve this function. Separation of in-going and out-going transfer of goods and persons is preferable. Transition areas include ambulance, trolley decontamination, CSSD, laundry and waste bagging areas, patient locker area and staff change areas with spaces for donning and doffing of PPE.

=== Site layout and master-planning ===
Spatial configuration and layout can ensure unnecessary cross-over of function is avoided. This entails the systematic separation of functions and the managed transition between activities to facilitate consistency of care, an orderly, efficient work environment, less waste and reduced risk for improved outcomes. To achieve this, functional relationships should first be considered at the site level before being considered at the building level. 

<gallery mode=packed heights=300px style="text-align:left">
Layout for a SARS facility, clustering functions with minimised cross-over.png|center|thumb|Layout for a SARS facility, clustering functions with minimised cross-over <ref name="Layout1">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Layout_for_a_Patient_cohorting_strategy.png|center|thumb|Layout for a Patient cohorting strategy <ref name="Layout3">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Tygerberg Hospital virus triage unit site layout.png|center|thumb|Tygerberg Hospital virus triage unit site layout <ref name="Western Cape Provincial Government, 2020a">Western Cape Provincial Government, 2020 a</ref>
</gallery>

The WHO's Clustering Layout <ref name="Layout1"/> and Tygerberg Hospital virus triage unit<ref name="Western Cape Provincial Government, 2020a"/> show worked examples of building and site layouts, which are configured with these principles, respectively. '''Cohorting''' is defined as clustering patients with similar or compatible clinical needs together for risk reduction, acuity, efficiency and quality management, as illustrated in WHO's Cohorting Layout <ref name="Layout3"/>

=== Workflow ===
Within individual functional zones, the workflow activities can be arranged to proceed from clean procedures to contaminated procedures. In the example below, the staff arrival, PPE donning, doffing and patient flows are worked to have controlled interaction and minimised cross-over

<gallery mode=packed heights=400px >
ACS HCW Flow.png |ACS Health Care Worker Flow
COVID-19 Workflow in small unit.png |COVID-19 Workflow in Small Testing Unit <ref name="Western Cape Provincial Government, 2020b>Western Cape Provincial Government, 2020 b</ref>
COVID-19 Workflow in large unit.png |COVID-19 Workflow in Large Testing Unit <ref name="Western Cape Provincial Government, 2020b"/>
</gallery>

As far as possible, a single direction flow of clean to dirty is recommended for all processes: support services, supply and waste.
The Small ACS unit workflow diagram<ref name="Western Cape Provincial Government, 2020b"/> illustrates the recommended separation of access and exit, separate waiting seats, for persons who may be COVID-19 infected. Separate spaces are provided for donning and doffing PPE. Staff change areas are provided.

In the Large ACS unit workflow diagram <ref name="Western Cape Provincial Government, 2020b"/>, there is a clear separation between staff areas and patient areas. Waiting seats are set far apart to reduce transmission risk. Staff change rooms are provided near the point of entry to the facility for staff to change from street clothes into medical work clothes. To prevent work clothes worn inside the facility from contaminating street clothes, these are kept in separate lockers. A step-over barrier from dirty to clean sides of the change room is helpful to enforce a mind-set of avoiding cross-contamination. Bins for contaminated garments are to be provided in change rooms. Shower facilities are to be provided for staff.

== '''Operational Strategies''' ==
=== Cleaning, disinfection and decontamination ===
Surface and substrate specification, and detailing of all areas should, as far as possible, allow for frequent:
*Cleaning with detergent and water.
*Disinfection with 75% alcohol solution (metal surfaces).
*[https://en.wikipedia.org/wiki/Sodium_hypochlorite Sodium hypochlorite] (1,000 ppm)/ Household bleach.
*Disinfectants listed on the EPA List N<ref>The United States Environmental Protection Agency, [https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 List N: Disinfectants for Use Against SARS-CoV-2 (Last Visited 2020) ]</ref> (for non-critical environmental cleaning).
*High-intensity ultraviolet surface disinfection (UV-C).
*Decontamination and sterilisation of clinical equipment.

=== Goods and waste management ===
Remove any unnecessary furniture, equipment and paraphernalia from all patient care and clinical areas. Provide a clear, secure space for waste management. Any potentially infectious waste materials generated at the ACS should be considered and treated as medical waste (health care risk waste). The applicable legislation is:
*[https://www.gov.za/sites/default/files/gcis_document/201409/35405gen452.pdf The National and Provincial Health Care Risk Waste Management Regulations].
*[https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf National Department of Health COVID-19 Environmental Health Guidelines.]<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>
Waste disposal bins should be positioned near the exit inside each patient rooms or wards to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another patient in the same room.

=== Materials and finishes ===
Floor materials must be:
*Level,
*Free of dust and oil,
*Impervious and smooth,
*Slip-resistant in wet areas (e.g. patient ablutions).
Smooth, cement screed floors are acceptable. Where hosting facilities have carpeted areas, a risk assessment of factors such as durability, hygiene and decontamination needs to be conducted. In cases where the acceptance of carpeted flooring is contradicted (but other factors make it a compelling option), temporary floor finishes or covering can be investigated.

== '''Personal protection''' ==
=== Hand sanitation ===
Where wash-hand basins are not provided, clinical wash-hand basins should be installed, at the minimum rate of provision of one wash-hand basin per 5 beds. Clinical wash-hand basins (see figure below) have a variety of features not present in standard wash-hand basins, which are preferable for infection prevention and control. Where standard wash-hand basins are provided, an upgrade is not necessary. In all cases, there should be no surfaces and no clutter, equipment or supplies in the vicinity of wash-hand basins, including surgical gloves.
<gallery mode=packed heights=400px>
Clinical hand wash basin.png|Handwash Basin <ref>de Jager 2020</ref>
Portable Wash-hand Basin.png|Portable wash hand basins can be provided in ACS <ref name="BDPa">BDP 2020, NHS nightingale instruction manual, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf</ref>
</gallery>

Where wash-hand basins are not available, portable units can be used, as shown above<ref name="BDPa"/>. Mounted brackets for hand sanitisers are to be provided for every two beds, preferably mounted near the foot rather than the head of the bed and at all common touch points such as entry points at ablution facilities, linen room, sluice, storerooms, medicine rooms/cupboards, near refrigerators, telephones, light switches, at entry/exit doors, etc.

=== Personal protective equipment ===
Donning and doffing points for personal protective equipment, and convenient, safe disposal of consumables to be placed at critical key points when entering patient areas.
----

== '''General transmission mitigation''' ==
=== Water and sanitation ===
To comply with National Building Regulations; Hazardous Biological Agents Regulations and National Department of Health COVID-19 Environmental Health Guidelines<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>.

=== Droplet aerosolisation ===
When designating areas for procedures during which aerosolization and airborne transmission risk is high, the building ventilation must be carefully considered to take into account downstream risks. In particular, consider to where potentially contaminated air, arising from aerosol-generating procedures, is exhausted. In general, air exhausted directly to the outside is diluted and considered safe, unless there are openings to occupied spaces near the exhaust air outlet. 

In the event that potentially occupied spaces will receive partially diluted or undiluted contaminated air, or where this is indeterminate, the aerosolising activity should be designated to an alternate area. In the event that an alternative is not available, some treatment regime (air filtration or air disinfection) is necessary. 

In most naturally ventilated settings, the airflow direction between zones may fluctuate according to the wind direction. Such high-risk spaces should not be adjacent to spaces with high susceptibility rates, such as PUI areas and uncontaminated areas. Contaminated areas should not be directly adjacent to clean areas unless mechanically ventilated. 
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|Guidance on COVID-19 building ventilation design is provided here]].

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Health, Safety and Well-being''' ==
In addition to the infection prevention and control measures discussed above, the following should be provided for health, safety and well-being.
=== General provisions ===
*Minimised and controlled entry and exit points, with suitable control.
*Clearly identified accessible and marked routes for patients, staff, goods and waste.
*Clear designation of restricted zones.
=== Site level provisions ===
*Safe staff parking and arrival of staff via planned and public transport.
*Clearly demarcated parking for people with disabilities.
*Arrival and departure point for patients via public transport, passenger vehicles, and emergency service.
*Limited safe patient parking.
*Supply of goods and removal of waste.

=== Within and between buildings ===
*Entrances with a clear opening width (CoW) of at least 900mm.
*Routes with a minimum width of 2 000mm free of hazards, for example, rubbish bins.
*All clinical, patient and support areas to be accessible by trolley.
'''Ramps''' should be of stable construction, capable of sustaining a mass of 300kg. They should incorporate side lips and the surface should be slip-resistant. Gradients should be as gentle as the circumstances allow. (Recommended maximum 1:20). 
'''Small changes in floor levels''' are not desirable, but where these exist are to be clearly marked with reflective paint/ tape, and lit at night
Elevators between different floors, where patients need access (The recommended minimum lift size for patient trolley/stretcher movement is 1 400mm × 2 400mm, however, this may not be possible). 
'''Pathways''' to be lit at night, where used at night. 
'''Staircases''' must be well-lit at night with non-slip surfaces and secure balustrades. 
'''Doors''', Double doors and automated or push-operated doors to all clinical areas are to be preferred, where these are newly installed or able to be retrofitted. Door closers are to be disabled, where not necessary to reduce touch surfaces. Hand sanitisers to be provided at where high touch common surfaces occur (e.g. wall-mounted at doorways).

=== Signage ===
The appropriate level of information to facilitate legibility, orientation and wayfinding. Minimum standards, signage to be:
*Clearly visible, simple font, font size, contrasting colours, placed in the field of vision
*Washable
*Comprehensive safety signage - fire signage (exits, equipment etc.)
*Restricted areas clearly marked
*Identification signage - each patient space to be allocated a unique number and a whiteboard or perspex sheet for writing the patient’s name
Signs should be posted immediately outside of patient rooms indicating appropriate IPC precautions and required personal protective equipment (PPE).
Signage of a temporary nature can be provided on laminated white A4 sheets attached eye-level. The text should be black sans-serif (for instance Arial) text at least 40point size and centrally positioned on the sheet. Detailed guidance on signage is provided in IUSS Inclusive environments.
=== Safety and security ===
Upon identification of the ACS host site, a team should be convened to conduct a multidisciplinary safety and security analysis. These critical team members need to form the working committee responsible for undertaking the detailed assessment of the existing facility’s security. They should analyse data about the security system’s condition and review existing security concerns or issues that are reasonably likely to become concerns in the near future. The figure below represents a five-zone approach to security, which is a recommended, systematic approach to security.
[[File:Zonal approach to security.png|center|600px|thumb|IUSS Security- Zonal Approach to Security <ref name="IUSS Security">IUSS Hospital design principles - Security [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file]</ref>]]
The security strategy should take into account that whilst clinical services and some logistical and support services will be required 24 hours a day, seven days per week, some support services, logistics services and auxiliary services may only be operational for the minimum periods required to meet demand. These functional elements should be capable of being secured, for example over weekends and at night, as the case may be.
Detailed guidance is available in [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file IUSS Hospital design principles - Security] <ref name="IUSS Security"/>

=== Comfort and dignity ===
Supplemental heating: Patient health and comfort are dependent on, amongst others, maintaining body temperature. The ACS structural technology must be selected to achieve the general indoor environment conditions discussed in a subsequent section for all clinical and occupied areas. As we are moving into South African winter supplemental heating may be required, especially in the evenings, in order to avoid hypothermia. Use of fans, bar, radiator or gas heaters should be prohibited. Unless clinical areas can be maintained above 18 degrees centigrade, patients should each have an infrared heater available, in addition to blankets. Personal/ donated blankets can be considered if they are laundered first and could be destroyed upon discharge.
Mobile screens should be available to provide privacy where necessary (e.g. during consultations or procedures).
<gallery mode = packed heights = 400px>
Bed_Isolator_-Vietnam.png|thumb|Flexible Barrier Isolator<ref>WHO. (2020), Severe Acute Respiratory Infections Treatment Centre. Geneva, Switzerland : WHO- World Health Organization</ref>
ACS Cohort beds.png|ACS Cohort beds.png|thumb|Excel Centre London 04-2020 <ref>Architects' Journal 2020, [https://www.architectsjournal.co.uk/news/nhs-nightingale-bdp-on-the-first-nine-days-converting-the-excel-centre/10046749.article https://www.architectsjournal.co.uk/news]</ref>
</gallery>
Some solutions which address patient privacy and dignity are depicted above.

=== Notes ===
<references/>

== '''Schedule of Accommodation''' ==
Based on clinical needs of the ACS, a schedule of accommodation can be crafted capturing the clinical, clinical, logistical, support and auxiliary services associated with the render of care. When deriving a schedule of accommodation, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital tool can be used. Functions to be accommodated are: 
'''Clinical services''': Triage, rapid assessment of persons entering the facility, to expeditiously identify and render the appropriate service. Admissions and registration. Inpatient accommodation is to be organised according to cohorting principles, discussed above. Testing and diagnostics, including laboratories and x-ray. Safe storage and dispensing of drugs to patients.Offices for clinical administration and clinical planning meeting rooms in the clean zone are needed. 
'''Logistical services:''' Logistical services will entail management of flows of people, goods, services and information to and from the site, as well as within the site. It includes security and communication arrangements. Staff entry, preparations to transition from outside to clinical work environment, including pause areas for relief. Emergency services, visitors. Goods, supplies and storage and waste removal and/ or treatment.
Support services key to the provision of clinical services should be separated so that the risks associated with that particular activity can be managed. 
'''Support services are:'''
*Laboratory services
*Catering
*Laundry
*Environmental cleaning and housekeeping
*CSSD
*Maintenance and cleaning of surrounds, eg. waste areas
*Porters/”runners”, stretchers/wheelchairs
*Mortuary
* Security
Support services can be provided off-site, in which case, safe, secure and efficient transfer and logistical arrangements should be designed. 
'''Auxiliary services:''' Auxiliary services are services which may be provided on or near the ACS site, but which are not directly related to core clinical care. This included overnight accommodation for staff who may not wish to return home to avoid exposing their families, or who need rest between shifts, or for discharged patients awaiting transport home, volunteers who have recovered from SARS-CoV-2.
Limited psychosocial services and allied health services may also be provided on or near ACS for example by approved partners.
Examples of schedules of accommodation for patient and support spaces for a protective isolation ward is available [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedule for COVID-19 Isolation Wards|here]] and mild to severe cases [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedules for COVID-19 Wards for Mild to Severe Cases|here]].

== '''Clinical Services''' ==
=== Triage ===
Confirmed COVID-19 cases and PUIs who are referred from a testing facility or a higher level of care, will enter the facility in a triage area to receive vital screening and initial assessment. They will be registered and admitted to inpatient care. They will be assigned a "ward" or section of the facility - based on disease status and acuity. These are Protective Isolation, the Mild & Moderate ward, or the Critical & Severe wards. Patients should be clustered according to gender. As far as practicable, ablutions for each gender, isolation patients, paediatrics and staff shall be separately provided. Paediatrics patients, if admitted, are to be assigned a dedicated section.
As patients recover or deteriorate, they may be relocated to the appropriate section/ ward.
Once the patient has sufficiently recovered and a negative test result is received they will be appropriately decontaminated and discharged, collecting medication from the dispensary on exit. Patient movement between various sections of the ACS will be restricted as far as possible, with mobile radiology units, in-ward medication dispensing and in-ward food service.

=== Inpatient ACS accommodation ===
Separate spaces for:
*suspected, unconfirmed cases, under observation (PUIs), to be accommodated in isolation facilities (separate rooms, if possible);
*patients with confirmed COVID-19 with mild to moderate disease, not requiring dedicated oxygen therapy;
*patients who require dedicated oxygen therapy;
*patients requiring mechanical ventilation; and
*recovered/ confirmed negative.
==== Protective Isolation Facilities ====
Suspected, unconfirmed cases, under observation – persons under investigation (PUIs) to be accommodated in protective isolation facilities (separate positive-pressure rooms, if possible). PUI are restricted to their rooms. All food and laundry services will be brought to the PUI rooms to reduce interaction and potential contamination. All waste will be collected by facility staff and taken to waste handling areas. Infection prevention and control measures are put in place for the handling of used food utensil and laundry as well as waste collection. PUI areas will have restricted access, including for staff serving other inpatient sections, for confirmed cases.

==== Inpatients accommodation for confirmed COVID-19 ====

Inpatient facilities confirmed positive COVID-19 can be accommodated in large shared ‘wards’ with partitioning between patients. Partitioning between patients is optional. Partitioning is preferable to curtains found in conventional hospitals, as they are more conducive to daily cleaning. If curtains are used, antimicrobial treated fabrics with biocide used to treat the curtains has been tested to international standard EN 14476 and shown to be effective against H1N1 Influenza A Virus (Swine Flu), >99.999% kill rate in 5 minutes and measles morbillivirus, >99.99% kill rate in 5 minutes are preferred. If only separate rooms are available, patient monitoring and surveillance will need to be accommodated. This phase of treatment has a lower area/space requirement compared with PUIs, as cross-infection between patients is less of a concern. Shared ablution facilities are acceptable. It is recommended that, at least, two general accommodation ward areas be provided. 

a) Mild and moderate patients, and 
b) Serious and critical patients. 

The room must have openable windows for natural ventilation if a dedicated positive pressure ventilation system is not available. Ducted ventilation systems shall not be shared between PUI areas and confirmed COVID-19 patient areas. 
[[File:COVID-19 ACS - protective isolation – bed layout.png|thumb|center|800px|ACS - protective isolation – bed layout]]
[[File:COVID-19 ACS – mild-moderate patient bed layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient bed layout]]
[[File:COVID-19 ACS – mild-moderate patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient shared ward layout]]
[[File:COVID-19 ACS – severe-critical patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – severe-critical patient shared ward layout]]

Examples above show bed layout with bed spacing for protective isolation, a mild/moderate patient and a mild/moderate patient shared ward and for a severe/critical patient

=== Patient services ===
Patients in ACS will not generally be ambulatory and will be confined to their room, or cubicle in a bed. In general, domestic beds or hospitality industry (hotel) beds are not suitable for patient care. These should only be used where a hospital-grade bed cannot be sourced, as hospital beds are designed for ease of cleaning and decontamination (for infection prevention and control) and with patient and ergonomics, safety and comfort taken into account (they prevent back injury for nursing staff and can help to prevent bedsores). The higher the specification of bed, the more suitable it is for the higher levels of care. Lockers for patients personal belongings should be provided in the uncontaminated zone (in which case bedside lockers will not be necessary), and it is preferable (where bedside lockers are not provided) for overbed tables to be provided, per bed, if possible. 
The following beds are suitable:
*Repaired and refurbished beds from condemned hospital stocks.
*South African National Standard, SANS 521:2013 Edition 3.5, on Hospital beds and cots ISBN 978-0-626-28830-3.
*Beds listed on the National Treasury (See [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Hospital Bed Specification|specification]]).
The table below details the minimum services required at each patient bed. Details on these services are discussed in a subsequent section of the document.

{| class="wikitable"
|-
! Service/ Capacity!!Triage!!Isolation !!Mild – moderate inpatient!!Severe case wards!!Critical case wards
|-
| Power – 16A 230V Single socket outlet||As needed ||1 per bed||1 per bed||3 per bed||6 per bed
|-
| UPS Power – 16A 230V Single socket outlet ||As needed||1 per bed||1 per bed||1 per bed||2 per bed
|-
| Medical Air<ref group="Note">Mobile units recommended for intermittent use. 3 per 20 beds</ref><ref group="Note">There are some ventilators which have built-in compressors allowing them to function without Medical Air. This is however, not the norm. With Ventilators probably being the most difficult medical device to obtain at present, it would be prudent to rather allow for Medical Air at each bed.</ref> (LP)400kPa||No||Yes||No||Yes||Yes
|-
| Medical O2 -400kPa||Portable/shared||Portable/shared||No||One||Two
|-
| Vacuum-40kPa||No||Portable/shared||Portable/shared||Yes||Yes
|-
| Equipment rail||||||||Yes||Yes
|-
| Upper room UVGI||Optional||Optional||||||Optional
|-
| Examination light||No||No||Yes||Yes||Yes
|-
| Room Ventilation rate||60 L/s per person||10 L/s per person||10 L/s per person||10 L/s per person||12 ACH
|}
'''Notes: '''
<references group="Note" />

Two additional 16A 230V single socket outlets, one two-pin outlet and a worktop should be provided for every 32 beds (or part thereof), for:
*Electrocardiograph (ECG): Could be omitted if monitors have a full 12 lead ECG function.
*Blood gas analyser: Could be omitted if a Lab Services are available.
*Staff cellphone charging.

Example of healthcare technology to be provided for critical care patients is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]. Severe patients may be provided continuous positive airway pressure (CPAP). Emergency trolleys (“crash carts”) are to be provided in patient areas with convenient access to patient beds, out of the passage of corridors and is moved to the patient when needed. 1 crash cart for every 16 patients (or part thereof, with at least one dedicated for PUIs. An example of provisions for a crash cart is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]
==== Patient ablutions ====
[[SARS-CoV-2 is found in faecal matter]], so careful management of patient body fluids is crucial and convenient, practical support for frequent cleaning of ablutions especially shared ablutions is necessary. Dedicated ablutions (toilets and showers) are to be provided for patient use. Toilets and showers should be in separate rooms.
Hand washbasins and or/ hand sanitiser should be provided both inside and outside the toilet room so that patients can wash their hands on the way in and on the way out of the room.
*1 toilet for every 8 persons.
*1 shower for every 8 persons.
*1 disabled ablution for every 8 regular ablutions (or part thereof).
*1 disabled shower for every 8 persons (or part thereof).

Critical and severe patients may be sedated and have a reduced need to access ablutions, ablution facilities proximity and provision can take this factor into account. Showers and wash hand basins should have hot and cold running water. Where possible ablution facilities must have openable windows for natural ventilation, if not possible the bathroom extraction and room ventilation system must be reviewed before admitting patient '''(see [[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|ventilation]]).'''

Portable toilets and showers may be used, provided that suitable hand wash facilities are provided. These will need to be suitably located, preferably in decentralised clusters, so that patients can easily access them without needing to walk very far. Ablutions should be located and designed in such a way as to provide visual and acoustic privacy, dignity and avoid disturbance of other nearby patients when accessing, using or cleaning the ablutions. Separate ablutions are to be provided for PUIs and confirmed patients.

====Makeshift sluice areas ====
In conventional hospital settings, sluice rooms are provided for cleaning and sanitation of soiled equipment, such as bedpans. In a temporary setting, such as an ACS, the establishment of a temporary sluice room may not be practicable, and there may not be facilities for emptying buckets, rinsing equipment etc.. The following is suggested:
Allocate a toilet, hand wash basin, not in splash range and restrict access to it for draining buckets and install a macerator for disposal of disposable bedpans. Electrical, water and waste supply points required as per supplier specification.
==== Dedicated patient treatment areas ====
The following dedicated, private spaces per ward for clinical procedures are recommended:
*Counselling and consulting room (can be shared), as shown in the figure below
[[File:Consulting room example layout.png|400px|thumb|center|Consulting room example layout]]
*Minor procedures room, as per the example provided in the figure below 
[[File:Treatment-minor procedures room example layout.png|400px|thumb|center|Treatment / minor procedures room example layout]]

== '''Logistical Services''' ==
=== Communications ===
Electronic communication should be facilitated in all zones of the ACS by the provision of device charging stations, and wifi.
=== Visitors entry point ===
Visitors are strongly discouraged from entering the ACS.
*In paediatric wards, one parent may be accommodated to visit a patient. In such cases, direct access for the visitor should be provided so that the visitor does not need to pass through the general patient area. Appropriate PPE must be donned before entering the patient area and hand washing/sanitising must be done when exiting the area.
*Non-patients who are accompanying suspected patients to the facility for testing or admission must be accommodated in a well-ventilated, spacious waiting area. Signage in such waiting areas must inform visitors about symptoms, hand hygiene and PPE.
*Hand washing/sanitizing facilities should be provided.

=== Staff areas ===
==== Staff change rooms ====
A minimum of 9m² or 4m² for a single person, increasing by one m² for each additional person is required. The clean (street side) and dirty (contaminated facility side) of the change room should be separated by a step-over barrier.

==== Staff rest areas ====
Staff rest areas within the main facility should be provided with access to kitchenette facilities and staff ablutions.
=== '''Staff auxiliary services''' ===
'''Staff on-call:'''Since staff may be required to work long hours or could be required to be on-call, shared, overnight sleeping facilities can be provided for staff on duty, outside the contaminated area, but in close proximity on the patient areas. An example is set out in the diagram below.
[[File:Example of on-call sleeping area for staff.png|center|600px|thumb|Example of overnight sleeping area for staff]]

'''Staff accommodation:''' It is advisable to provide some staff accommodation for off-duty staff who may not have suitable alternatives, for example homes too far away, transport limitations or the requirement not to expose family members to risk. This should be provided in the vicinity of the ACS, but in a physically separated zone. This amenity can be outsourced.

== '''Support Services''' ==
=== Workflow principle ===
[[File:Linen processing cycle.png|none|thumb|Linen processing cycle <ref>IUSS 2014 [https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department]</ref>]]
Progressive workflow from “dirty” (that is contaminated) to “clean” linen is advisable to reduce the risk of exposure to contaminated materials. The workflow diagram below, showing the progression from the dirty linen receiving area, to the cleaning process, to decontamination and drying, and finally sorting and packing, and storage, illustrates this principle.
=== Laboratory ===
[[File:Example of modular laboratory.png|right|thumb|Example of modular laboratory]]
The WHO recommends the following laboratory diagnostic equipment be accommodated:<ref>WHO 2020, [https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items]</ref>.
<nowiki>• Lab screening test kit
• Lab confirmation test kit
• RT-PCR kit
• Extraction kit
• Cartridges for RT-PCR automatic systems
• Swab and Viral transport medium
</nowiki>
Additional accommodation requirements are:
# Reception counter- receiving specimens
# Testing with perspex/ glass screen
# Receiving/Data capture
# Specimen holding
# Toilet - staff
# Blood storage fridge
Can be provided as a modular laboratory unit as shown in the diagram.
=== Pharmacy ===
The purpose of the pharmacy is to provide medicines needed for inpatient treatment and care.
All medical supplies should be stored in a secure, climate-controlled area in close proximity to the patient treatment area. The pharmacy must have dry, lockable, climate-controlled storage of medications. Most pharmaceuticals are labelled with storage temperatures. The pharmacy should have adequate ventilation through an openable window to prevent humidity from building up in the room. Air-conditioning or mechanical ventilation can be provided, if necessary.

Dispensing areas must be well lit. Worktop in space for stock records and administration. Dispensing counters to have perspex or glass screens to serveries. Social distancing implemented at counter, between pharmacists/assistants and between chairs in waiting area.

Can be provided in a mobile unit.

=== Radiology ===
The purpose of radiology services is to provide chest X-Ray services for COVID-19 diagnostics. In general, CT scans, bucky rooms etc. associated with some radiology equipment require specialised infrastructure and therefore is not suitable for ACS. Radiology services can be provided as a mobile floor standing unit, or containerised unit. Alternative technologies such as Lodox and hand-held ultrasound devices are being investigated as potential options and could be confirmed as suitable for use in due course.
=== Laundry services ===
All dirty linen should be handled for bagging or binning inside the patient room/cohort area. The clean linen stock should be stored conveniently close to clinical areas, in a dedicated clean area in the uncontaminated zone. Used linen should be stored in a designated, safe, lockable holding area while awaiting collection. Interim storage areas for soiled linen at the wards is allowable; this may be in dirty linen/ utility room.
Any clean linen for PUI areas should be handled in spaces physically separate from dirty linen of confirmed patient areas. It may be necessary to completely separate PUI and confirmed patient linen streams. Soiled linen and clean linen bags and bins should be dedicated and not mixed.
Full laundry cleaning and drying services may be provided on-site or outsourced. If laundry cleaning and drying services were already rendered on or for the host site before it is repurposed as an ACS, then a suitability and risk assessment should be conducted to ensure that the volumes of laundry generated and infection prevention and control measures are conducive and modifications made as necessary. A new full laundry service may take time and resources to establish, and in general, will not be established at a host site as a temporary solution. Where the site and circumstances advocate for the design of a new laundry or the upgrade of an existing laundry, the IUSS Laundry Services for Hospitals should be applied.
==== Siting and model selection considerations ====
When an existing laundry is being assessed for use or a new one is being planned the following considerations apply:
* Water and power capacity.
* Ease of access to the ACS’s main corridors and internal transport routes.
* The noise factor of the facility and its impact on nearby patient care departments.
For outsourced departments:
* Delivery areas to allow sufficient space to ensure that vehicles can manoeuvre and park easily at the reception and dispatch bays.
* Access to the ACS service roads and public roads.
==== Functional requirements ====
The most basic equipment needed in a laundry includes washing machines, tumble dryers and ironing machines. Equipment requiring steam is not recommended for a temporary facility. The sizing of the laundry, equipment and engineering services can be modified based on the principles provided in the IUSS Laundry and linen.
=== Catering services ===
Kitchenettes, that is, areas for tea, coffee and snacks, mainly for staff, in staff pause areas are discussed elsewhere in this document.
Catering services (for staff and patients) may be provided on- or off-site. If the ACS is to be established with easy access to a suitable, existing, functional kitchen service (e.g. hotel, military or hospital catering) which can meet the additional demand of the ACS, then this should be used. If there is no suitable facility, catering should be outsourced via a suitable off-site supplier. Only in the event that no feasible or suitable, existing facility or local supplier is available, should a new catering service be established at the ACS. Detailed guidance for the sizing, design and layout of catering services can be found in the IUSS Catering Services for Hospitals.
The kitchen (for on-site catering) or preparation area (for off-site catering) should be located with easy access to the point of delivery and storage of food. Adequate food and equipment storage space must be provided.
It is recommended that patient and staff meals, where provided, be supplied in disposable, containers, suitable for incineration, and that these are disposed of as risk waste immediately after use.
Where off-site catering is used, a suitable area for receiving should be provided. Space will be required for sorting meals for distribution and collecting and storing dirty dishes, washing dirty dishes, if necessary, and disposing of left-over food and disposable containers and utensils. The size of the areas required for this will depend on the number of meals delivered.

=== CSSD ===
The primary function of a Central Sterile Supply Department (CSSD) is to provide an efficient, economic, continuous and quality supply of disinfected and sterilised items, when needed, to all patient-care service points in the ACS, and to receive returned contaminated items for cleaning.
CSSD with limited sterilisation capacity (autoclave) but sufficient disinfection capacity (instrument washing). The layout requires a designated clean and dirty areas with a hard barrier between to avoid cross-over of staff and equipment. Work is unidirectional - flows from dirty – to clean - to sterile areas.
This yields three distinct zones:
1. Receiving and cleaning with pass-through windows
# Dirty receiving with Perspex or glass partitioning
# Dirty utility
# Decontamination and cleaning/wash area with throughput instrument washing
# Trolley wash/Park – external
2. Inspection, assembly and packaging with pass-through windows
# A tabletop autoclave
# Instrument washer
# Clean Packing area
3. Sterile processing, storage and distribution. (Separate issuing area from receiving area) with pass-through windows
# Store -linen and consumables
# Sterile pack store
# Issue - Collection hatch with Perspex or glass partitioning
Must also have a secure, separate receiving area for consumables receiving and storage.
An example of a CSSD unit is shown in Figure 21.T

[[File:An example of a small CSSD facility.png|600px|thumb|none|An example of a small CSSD facility<ref>IUSS 2014, https://www.iussonline.co.za/norms-standards/support-services/24-central-sterile-service-department</ref>]]

To be understood: Quality of services, eg. water (including a source of distilled or ionised water for rinsing of bronchoscopes) and electricity, quality of management, if equipment is appropriate for needs and fit for purpose, what is required of the equipment in the near and far future (relocation?), compliance with S.A. National Standards for CSSD, compatibility of equipment and devices, correct chemicals, maintenance of equipment, training of operators. Although the use of disposable breathing circuits and accessories (masks) should be encouraged, the capacity to disinfect these items if disposable is not available must be considered.

The CSSD must be sized to serve the ACS. Considerations are workload and space requirements. CFSA has extensive [https://www.fidssa.co.za/Content/Images/CFSA_SOP_2018.pdf standard operating procedures] for CSSD.

Workload: Number and type of procedures, number of procedure rooms, eg for bronchoscopy, operating hours, available inventory, volume of work and peak times, degree of mechanization, eg. manual or automated instrument washing, amount of product to be stored – chemicals, barrier wrap, chemical indicators, etc., storage and distribution records, quality records – eg. equipment checks, disposal needs.

Space requirements: Space for separation of clean and dirty, allow for unidirectional movement, allow space to manoeuvre trolleys (queue, pack/unload), reduce lifting and carrying heavy items, reduce awkward movements, allow for tidy work areas. Insufficient space will compromise sterility!

Preference should be given to construction materials and finishes which are suitable for frequent cleaning and tolerant to chemicals, including bleach (sodium hypochlorite). Impermeable flooring, non-slip and smooth washable walls are needed. Joints at walls and floors and coving at wall edge, and exposed drains should be avoided. Worktops should be sealed and should be ergonomically suitable.

Ceiling heights below 2.8m may be vulnerable to damage from humidity Where steam and moisture are generated. Noise – insulation of washer-disinfector and steriliser in technical walls will reduce noise. Lighting: Natural light if possible – windows sealed. High luminance if artificial lighting. Open, slatted shelves for sterile store area. Sinks for manual washing: At least two basins, deep (25cm at least) basins, 91 cm from floor, wide and long enough for the biggest instrument tray or container, water ports for flushing of lumens.

The CSSD space allocation and layout should be determine based on what procedures and which medical devices will be required. A typical [[equipment list is provided here]].

=== Maintenance and cleaning ===
Maintenance and cleaning services must be accommodated with offices located away from clinical areas.

=== Mortuary services ===
The National Department of Health has issued guidance on handling of dead bodies and infectious remains<ref>National Department of Health South Africa, 2020 [https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf]</ref>, which should be applied to ACS. While some guidelines have recommend that bodies of persons who have died from COVID-19 should only be held for a very brief period prior to cremation or treatment for burial<ref>Zhejiang University, 2020 [http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm]</ref>, the WHO holds the view (at the time of writing) that there is no evidence of persons becoming infected from exposure to bodies during normal ceremonial and burial activities. However, appropriate PPE should be used when handling such bodies with additional airborne precautions to be taken during autopsies<ref>WHO, 24 March 2020 [https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf]</ref>.

Either body cabinets or a refrigerated room could be used for body storage.
==== Location and layout of mortuary service ====
It is likely that not all alternative care sites will have a mortuary. Those without a mortuary must have a holding room that is located away from general access areas. This holding room must be suitably sized and conditioned. A recommended room size is 3.5 m x 3.4 m<ref>IUSS Adult Inpatient Services, 2014, [https://www.iussonline.co.za/docman/document/clinical-services/65-adult-inpatent-services-gazetted/file]</ref>
A mortuary should be located so that it is easily accessible to mortuary staff and related service providers and visitors without presenting either aesthetic, emotional or ethical problems for unrelated staff, patients or visitors. It should be separate from the general facility, allowing access for the family to view a body without passing through any potentially contaminated area of the facility. The visitors’ entrance should be external and completely separate from other access points.
Appropriate routes should be designated so that bodies are not moved through public-access areas.
==== Sizing of mortuary ====
The layout and size of a mortuary are largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.
==== Services ====
The following services are required in a mortuary:
* Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.
* Sluicing facilities are to be provided in both the body-preparation and autopsy areas if they are not a common area.
* Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush-fitted stainless steel grids.
* No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.
* The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.
* Anti-backflow devices should be fitted to the water-supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.
* Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.
==== Finishes ====
Wall and floor finishes should be impervious to liquids and easily cleanable.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Environmental Controls''' ==

== '''General Indoor Environment Conditions''' ==

Existing environmental control systems should be modified to suit requirements in the facility. The following issues should be considered:
* Systems should be set to maximise the introduction of fresh air and maintain the pressure regime (see ventilation).
* The following internal temperature range should be maintained 19 - 24oC.
* Cooling systems should be able to cater for projected internal heat gains from people, lighting and equipment. Indicative heat gains in treatment areas are 8W/m2 from people, 15W/m2 from lighting and 3 W/m2 equipment and in critical care areas 16W/m2 from people, 15W/m2 from lighting and 60W/m2 equipment.
*As heat gain can vary widely between items of equipment, heat gain and utilisation rates for equipment should be obtained from the manufacturer to establish this more accurately.

=== Solid waste from ACS ===
According to the National Department of Health COVID-19 Environmental Health Guidelines
“All solid waste from the facility should be regarded as potentially infectious material and therefore appropriate precautions should be taken". The management of healthcare risk waste (HCRW) should follow the correct identification segregation, storage and disposal processes as indicated in SANS 10248-1.

* HCRW is segregated at the point of generation and shall be containerized to minimize the risk of contamination.
* Waste generated from patients in isolation or quarantine in a designated facility health facility is treated as health care risk waste (HCRW) as per SANS 10248-1-2008.
* The HCRW is properly packaged in a sealed, leak and puncture-proof containers/ boxes.
* The HCRW is labelled with the biohazard symbol/ sign and marked “Corona virus or COVID-19”.
* The HCRW is stored separately from other waste generated.
* The collection, transportation, treatment and disposal is provided by only an appointed/ appropriate contractor/ service provider, however, ensure that waste is safely stored until the health care waste management company can pick it up and that the company knows and acknowledges that waste was generated by suspected or confirmed COVID-19.
* The waste management company collecting must ensure that and treated and disposal is conducted at license waste treatment/ disposal facilities .
* All personnel or staff in contact with patients must be geared with appreciate personal protective equipment (PPE’s) at all times to prevent exposure or risk to health.
* Monitoring should be done at such facilities.
* All, bags, bins and boxes must be adequately sealed, as not to leak any fluids, and must be wiped down with 0.05% chlorine solution

Measures developed should consider the following.
* Develop a waste management plan following national guidelines and best practice standards for the disposal of medical waste (WHO, 2020).
* Establish procedures with medical waste service providers to regularly pick up the waste and dispose of this safely.
* Provision should be made for 5kg of solid waste per bed per day and this should be monitored and supplemented where it appears this may be inadequate.
* Ensure that access to waste is secure and controlled, for instance, by using lockable waste 1000l containers kept in a location that can only be accessed by health facility and nominated service delivery staff.
* Vermin control programs must be implemented throughout the site with HCRW collection points prioritised
* Provision for safe cleaning and disinfection of reusable containers should be provided. Cardboard, single-use HCRW boxes are removed from site and incinerated.
* Waste must not be allowed to accumulate or be stored inappropriate or unsecured containers.

== '''Engineering Services''' ==
Engineering services include patient services, ventilation, electrical power, water, medical gases, oxygen, compressed air, vacuum, lighting, and fire safety that support the needs of the patients and medical staff under normal and emergency situations. Good practice standards are provided in:
* IUSS Building Engineering Services<ref name = "IUSSBES">IUSS 2017, [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file]</ref>
* NHS Nightingale Instruction Manual<ref name="BDP2020">BDP 2020, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf]</ref>.
The guidance below draws on these and other manuals and standards. 

=== Building ventilation ===
==== Mechanical ventilation ====
While SARS-CoV-2 RNA has been detected in aerosol form, in experimental mechanical aerosolization studies, it is primarily spread through droplet and contact spread and the potential for airborne transmission is thought to be low.
However, the following advice is provided by ASHRAE regarding HVAC systems in general spaces (not specific to healthcare):
Effective high levels of ventilation must be achieved in the facility. Existing ventilation systems should be tailored to suit internal layouts and requirements and the following measures should be taken.
* Mechanical systems should be set to maximise fresh air supply to the facility. There should be no recirculated air without HEPA filtration or other validated decontamination processes.
* A pressure regime should be established, as shown in figure 2, to 'push' air from clean areas, to dirty areas and then out of the building.
* A clean air supply of over 10 L/s per person should be targeted for odour control.
* Fresh air supply shall not be located near patient beds to avoid drafts in winter.
* Extraction points can be located near patient beds in isolation wards or at a high level in long-stay wards. Short-circuiting of air between high-level supply and extraction is a performance risk in winter.
* Noise from ventilation systems and fans shall be below 45 dBA
* Protected lobbies, internal partitions, door arrangements, fans and extracts should be used to maintain the pressure regime and airflow as indicated in the diagram below.
 

[[File:Ventilation in temporary facilities.png|600px|thumb|none|Ventilation in temporary facilities<ref name="BDP2020"/>]]

==== Natural ventilation ====
The airflow direction between naturally ventilated zones may fluctuate according to the wind direction. This is not of concern within and between contaminated zones where occupants are either protected with mandatory PPE or confirmed to be infected with disease strains similar enough so as not be able to reinfect others. Where levels of occupant susceptibility to an airborne disease is significantly different, the less susceptible areas (such as PUI areas and uncontaminated areas) shall be protected from the naturally ventilated and contaminated areas by mechanical ventilation systems with a capacity sufficient to overcome the expected natural ventilation pressure fluctuations (typically 5-15Pa). Where such mechanical ventilation systems are not feasible or expected wind pressure is too great, zone adjacently must be avoided.

===Ultraviolet germicidal Irradiation===
The application of Ultraviolet Germicidal Irradiation (UVGI) for room air disinfection is well understood and is proven to be effective in the disinfection of microorganisms including M. tuberculosis (TB) in air. UVGI should, therefore, be considered as a valid element in indoor airborne infection control strategy for high volume settings. Studies have demonstrated the importance of good vertical air mixing in the room, and the safety of UVGI application. In areas where UVGI is indicated, the design and development of UVGI systems should be in accordance with the [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]<ref>van Reenen et al,2019 [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]</ref>

=== Electrical power ===
Sufficient and reliable power must be available at the facility for envisaged medical equipment, medical gases, lighting and building ventilation equipment. Power installations for the temporary facility can be divided into three zones as indicated below. These are existing services, the temporary service zone and services in each bay.
The following should be considered by competent engineering professionals.

=== Existing services ===
*Capacity: Evaluate whether sufficient power to accommodate envisaged medical equipment, additional lighting and heating, building ventilation and air conditioning can be provided. If existing capacity is insufficient, investigate if it is possible to route additional power from additional locations/transformers around the site or from adjacent sites.
* Safety: The existing electrical distribution network must be able to supply the required equipment load. If this is insufficient/appears unreliable, identify how this can be supported.
* Resilience: Evaluate back-up power and a UPS capacity against essential services demand. If existing capacity is not sufficient, source and establish temporary service capacity.

=== Temporary service zones ===
*Identify locations for temporary service zones where equipment can be located.
*Ensure that equipment and maintenance access is safe and easy.
*Ensure that all distribution boards, circuit breakers and cables are clearly labelled.
=== Services in each bay ===
*Provide pre-wired power strips/trunking as per bay requirements.
*Check that these include sufficient electrical outlets and service points for envisaged equipment.
*Ensure that trunking will carry required equipment loadings. The IUSS Building Engineering Services Guide can be used to check requirements<ref name = "IUSSBES"/>.

[[File:Layout_of_power_in_a_temporary_installation.png|600px|thumb|none|Layout of power in a temporary installation <ref name="BDP2020"/>]]
----

=== Water ===
Water points are needed for handwashing, showers and cleaning. The following issues need to be taken into account.
==== Supply ====
Onsite cold water storage, dedicated to the domestic water requirements of the facility, should be provided. A minimum usable volume of 500 litres per bed should be available.
Hot water storage and consumption should be confirmed by an engineer, as follows:
*Storage 25 L per bed.
*Consumption 180 L/bed.day W/O laundry; 250L /bed. day W laundry.

==== Handwashing ====
See infection control for clinical wash-hand basins
==== Showers ====
Showers for staff coming off shift should be available. Staff flow routes exiting contaminated treatment areas should pass through gowning and shower areas.
----

=== Medical gases, oxygen and vacuum (suction) ===
Medical gases, oxygen and vacuum services will be required in the facility. Mobile gas supply requires piping between supply and patient and clutter floor space. Preferably used fixed installations for patient rooms/cubicles, if possible.

System capacity and point of use pressures and consumption rates are to be ensured at all points. WHO provides technical guidance on [https://www.who.int/publications-detail/oxygen-sources-and-distribution-for-covid-19-treatment-centres oxygen sources and distribution]. 
[[File:Medical gas service layout.png|6oopx|thumb|Medical gas service layout<ref name="BDP2020"/>]]
The following points should also be taken into account.
* For centrally supplied medical gas and vacuum services, system resilience and availability must be ensured.
* Compressors, tanks, accumulators, VIEs, headers and controllers must be secured from uncontrolled access.
* Where possible, gas piping should be reticulated below floors or in ceilings to ensure protection from tampering, damage and ease of access.
* Where reticulation is within open areas, high-level reticulation with point-of-use droppers is advised. Low-level reticulation within rooms is to be avoided.
* Flexible piping can be used, ensuring it does not present a contamination or fire risk and should comply with local regulations. Special care should be taken with flexible O2 piping, keeping it to a minimum.
* Vacuum piping may be contaminated, where point-of-use filtration and collection systems fail. Precautions should be taken when demounting or disconnecting temporary vacuum lines.
* Ensure that oxygen pipelines are designed to provide sufficient flow to all oxygen points in the facility. In terms of utilities, oxygen and medical air would be required. A temporary vacuum point can be provided by mobile medical vacuum units distributed throughout the unit.
* Mobile medical air supplies should be considered where reaching piped specifications are not feasible. Where flexible hoses are used for oxygen and medical air special precautions need to be taken. Flexible oxygen piping must be chemically safe for O2 use. Where perishable flexible piping is used for medical air, terminal filtration at the point-of-use may be required at point-of-use. Especially for long-term use.
* Electrical and gas services can be reticulated against pipe racks or boards fixed to the bed-heads for head to head bed arrangements.
* Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.
* Gas service outlets to be labelled and colour-coded with 3mm lettering.
* SANS 7396-1 should be used to specify the requirements from design to commissioning of medical gas and vacuum systems.
* Medical gas and vacuum pipelines shall be marked per SANS 7396-1 and ISO 5359, as applicable.
* Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.
* SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.
* Plain-ended copper tubing for low-pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.
* Laboratory gas taps and valves shall be marked as described in SANS 10140-4.

=== Lighting ===
Existing lighting systems may need to be modified to suit the clinical requirements in the facility. High bay lighting presents inadequate colour rendering quality for the accurate detection or easy diagnosis of certain clinical conditions. This needs to be evaluated in the selection of supplementary lighting systems.
*Lighting levels should be provided in line with the indoor lighting levels recommended in the Table 6 of IUSS Building Engineering Services .
*Mobile task lighting systems may be adopted in the serious and critical stay wards to supplement incorrect lighting quality.
*Emergency lighting and illuminated emergency egress signage should be linked to the back-up power system.
*External security lighting in external parking areas and spaces around the building should be enhanced to ensure the security of medical staff who need to change shifts at night.

=== Fire safety ===
A functional fire alarm system should be available to support the patient care setting. Fire is a very real threat due to the possibility of an oxygen-enriched atmosphere developing so ventilation is crucial.
The use of temporary facilities for medical care should note the following fire risks (NHS, 2020):
*Patients may have a very high dependency.
*Areas are not specifically designed for patients and do not meet guidance on fire compartmentation and progressive horizontal evacuation.
*Large numbers of patients supplied with oxygen up to 10 litres per minute.
*Possibility of oxygen concentrations exceeding those generally found in the atmosphere- less risk if effective ventilation or large volume i.e. high ceilings.
* Possibility of storage, in excess of 40 litres, of alcohol-based chemicals (such as hand-rub), necessitating a flammables cabinet on site.
*Staff who may not normally work together .
*Staff who may not be familiar with the area.
*Staff not trained in fire safety, progressive horizontal evacuation or oxygen isolation for the specific area.
These factors should be taken into account in fire risk assessments which should then address significant findings in an action plan. Fire assessments should be undertaken by a qualified person and shared with operations and building management staff within the facility. Measures developed should include:
*An automatic fire detection system
*An emergency egress plans are prepared that include patients who have a very high dependency.
*Signage, notices and lighting are installed and are working effectively.
*Management processes are in place to minimise the risk of fire from ignition sources, fuels and oxygen.
*Staff are trained and a fire safety guide sheet for staff is developed and issued.
*Emergency egress routes are kept clear.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Additional Resources''' ==
=== [[Directory of Service Providers|A Directory of Service Providers can be viewed here]] ===

=='''References'''==
<references />

[[Category:COVID-19| ]]
[[Category:Alternate Care Sites|Alternate Care Sites]]

----
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19|(Return to Top)]] 
----

Infrastructure Guidance for COVID-19/Alternate Care Sites

2020-05-08T08:34:50Z

Peta: /* Heading text */

[[Infrastructure Guidance for COVID-19|Return to Infrastructure Guidance for COVID-19]] 

== '''Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19'''==

This guidance work was initiated under the project titled: 
''Reducing Nosocomial and Community-Acquired Tuberculosis by Strengthening the Capacity of the South African Department of Health to Improve Implementation of Infection Control and Waste Management at All Levels of the Health System Under the President's Emergency Plan for AIDS Relief (PEPFAR)'' 

== '''Purpose and Approach''' ==
The global pandemic of COVID-19 caused by the coronavirus, SARS-CoV-2 is likely to result in a surge in need for medical care for Severe Acute Respiratory Syndrome (SARS) in South Africa. Considering the course of the pandemic in other countries, it is anticipated that South African hospitals will not have sufficient capacity to cope with the surge of persons requiring medical attention and that surge capacity via alternate care sites (ACS) will need to be established.
Surge capacity, contemplated here is not the frequent emergency department overcrowding experienced by healthcare facilities (e.g. Friday/Saturday night emergencies) or local casualty emergency that might overcrowd nearby facilities and have little to no impact on the overall healthcare delivery system. It is when a catastrophic event occurs and the affected population seek medical care from existing local healthcare facilities, causing healthcare infrastructure to become exhausted due to excess in demand. During a healthcare surge, the standard of care will shift from focusing on patient-based outcomes to population-based outcomes, and providers should anticipate “a shift to providing care and allocating scarce equipment, supplies and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals.”<ref>[https://asprtracie.hhs.gov/technical-resources/resource/491/altered-standards-of-care-in-mass-casualty-events Health Systems Research Inc., 2005]</ref> 

Surge capacity can be temporarily established in non-traditional environments, such as hotels, exhibition halls, community halls, and as field hospitals, on open spaces. 

In the context of this document, a quarantine site is a facility for patients who do not require continuous professional medical care, while an ACS is defined as a temporary facility that can provide continuous medical care for SARS. This document provides principles and considerations, high-level guidance for minimum requirements and examples for ACS. 

While an extensive set of health facility guidelines does exist<ref>[https://www.iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-servi IUSS Building Engineering Services (2017)]</ref>, these are applicable for conventional facilities and thus include services and guidelines that are not necessarily relevant to the treatment of a novel, highly infectious pathogen, with pandemic effects. Moreover, these do not provide well for the rapid and temporary establishment of facilities. 

In order to formulate high-level guidance, [[as invited by Business for South Africa]], the team reached out to professional industry bodies for inputs, in particular the South African Institute for Architects (SAIA), The Gauteng Institute for Architects (GiFA) [https://www.gifa.org.za/ Gauteng Institute for Architecture] and the [http://www.safhe.co.za/ South African Federation of Hospital Engineering (SAFHE)], by inviting input via a 36-hour research charrette. Relevant historical and contemporary literature was consulted, precedents identified and critically reviewed. An interaction with the team at Wuhan responsible for makeshift hospitals and emergency infectious diseases hospitals, Central-South Architectural Design Institute, was arranged with assistance of the Chinese Embassy. Material from the [[Infrastructure Unit System Support|Infrastructure Unit System Support (IUSS)]], international literature and guidance and input gathered from the broader architectural, engineering and healthcare professional communities was synthesised and moderated by the CSIR team. The draft was reviewed by an expert review panel. 
=== Acknowledgement of contribution ===
The contributions to the initial version of this were gratefully received. [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Acknowledgements|A list of these contributors can be viewed here.]]. 
New contributions are eagerly encouraged along with debate and discussion on the [[Talk:Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites|'''discussion forum.''']] tab above.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Scope and Assumptions''' ==
ACSs as discussed in this document are dedicated, temporary facilities for triage, testing, diagnosis, further referral and treatment of persons:
*suspected of having contracted SARS-CoV-2, (persons under investigation (PUIs)), who are symptomatic and/or are awaiting results,
*or are confirmed to be infected.
ACS will accommodate a variety of clinical, logistical, support and auxiliary services associated with the render of care. ACS will currently not be licensed to provide healthcare services. Since the ACS will operate in a non-healthcare facility, it cannot fully replace a hospital setting and its prime objective is to manage the patient load until the local healthcare system can meet demands. 

=== Exclusions ===
Quarantine facilities are accommodation facilities where a member of the community can remain for the duration of their isolation period. This is typically temporary housing for a cohort of people who do not need intensive medical attention but who cannot stay at home. Patients can take care of themselves and need limited monitoring by medical staff. Quarantine: Containing presumptive-case patients from each other and the general population.
Quarantine facilities – that is for asymptomatic persons who are in the community in self- or imposed isolation, but not displaying symptoms, or who are symptomatic, but are able to safely recover without clinical intervention and do not need continuous medical observation are not considered in this document.

=== Service regime ===
The following assumptions are made with respect to services under consideration.
* Temporary - limited to the part of the pandemic when the “conventional” hospital platform cannot meet demand. To be dismantled, thereafter.
* Uncomplicated, dedicated COVID-19 care is to be prioritised for ACS.
* Patients with comorbidities, paediatrics will be prioritised for conventional facilities, and only accommodated in ACS as a matter of last resort.
* 24 hour, 7 days a week operations. 

=== Assumed mechanism of transmission ===
Transmission of SARS-CoV-2 is understood to be from person to person firstly by [https://en.wikipedia.org/wiki/Transmission_(medicine)#Droplet_infection droplet] transmission, then by the [https://en.wikipedia.org/wiki/Transmission_(medicine)#Direct_contact contact] route and finally via airborne [https://en.wikipedia.org/wiki/Transmission_(medicine)#Airborne_airborne transmission] during or following mechanical aerosolisation. Water transmission risks are minor, occurring in special [https://en.wikipedia.org/wiki/Transmission_(medicine)#Fecal%E2%80%93oral Fecal-oral] circumstances. Reclassification of transmission mechanisms may nullify some of the approaches presented in this guidance. 

=== A call for strategic coordination ===
This document focusses on infrastructure requirements. These provisions are meaningless without staffing, equipping and resourcing. Whilst staffing, equipping and resourcing are not the focus of this document, these are likely to emerge as key constraining features. Resource constraints are likely to become acute during this pandemic. Doctors and nurses are already in critical short supply in South Africa and internationally, and are themselves susceptible to COVID-19 infection. Equipment and consumables are in short supply with heightened global demand, reduced manufacturing capacity and limits in trade flows. This necessitates strategic coordination, proactive planning, options appraisal and prioritisation. 

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Status Quo''' ==
=== Rationale and transmission status ===
According to the [https://en.wikipedia.org/wiki/World_Health_Organization World Health Organisation] (WHO), based on the largest cohort of COVID-19 patients, about 40% of patients with COVID-19 may have mild disease, where treatment is mostly symptomatic and does not require inpatient care. About 40% of patients have moderate disease that may require inpatient care; 15% of patients will have severe disease that requires oxygen therapy or other inpatient interventions, and about 5% have critical disease that requires the patient to receive mechanical ventilation. However, the evolution of the outbreak in some countries has shown a higher proportion of severe and critical cases and the need to rapidly increase surge capacity to prevent rapid exhaustion of biomedical supplies and staff. In some countries, doubling rates of cases every three days has been observed<ref>WHO-2019-nCoV-HCF_operations-2020, [https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf]</ref> 

South Africa has a high burden of disease, with a high prevalence of [https://en.wikipedia.org/wiki/HIV/AIDS_in_South_Africa HIV and TB]. Although evidence is yet to emerge of the effect of SARS-CoV-2 on a population with these pre-existing conditions, there is reason to proceed with caution<ref>The Conversation 2020, https://theconversation.com/tb-hiv-and-COVID-19-urgent-questions-as-three-epidemics-collide-134554</ref>. There is a potential direct and indirect benefit of ACS to people living with HIV and TB, as well as to general public health and the health system preservation. 

With the travel lockdown in place, and continued transmission, it appears that South Africa is on the cusp between cluster transmission and community transmission according to WHO’s classification, shown in the [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites#Key_clinical_and_infection_control_activities_for_different_transmission_scenarios_.5B3.5D|table below]], indicating that preparation should include temporary hospital facilities and mass critical care.

==== Key clinical and infection control activities for different transmission scenarios <ref>WHO 2020, [https://apps.who.int/iris/handle/10665/331492 https://apps.who.int/iris/handle/10665/331492]</ref> ====
{| class="wikitable"
|-
! !! '''No Case''' !! '''Sporadic Case''' !! '''Clusters of Cases''' !! '''Community Transmission'''
|-
| Faculty Space, Including for Transmission|| Usual Space. Enhanced Screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards). || More patient care areas re-purposed for COVID-19 within the health system, especially for severe cases || Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Staff|| Usual space. Enhanced screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards)||More patient care areas repurposed for COVID-19 within the health system, especially for severe cases||Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Supplies||
*On-hand supplies. Equip wards for COVID-19 treatment.
*Identify essential equipment and supplies, including oxygen.
*Prepare expanded local supply chain
||
*Expanded inventory of supplies with detailed protocols for use.
*Activate expanded local supply chain.
*Prepare national supply chain.
||
*Conservation, adaptation, selected re-use when safe.
*Activate contingency planning and procurement for essential equipment and supplies.
*National supply chain.
*Prepare expanded supply chain at the global level
||
*Activate contingency planning should critical equipment be in short supply.
*Determine allocation of lifesaving resources for HCWs and patients.
*Activate expanded global supply chain
|-
| Standard of Care|| Usual care with enhanced awareness and recognition of immediate needs for first COVID-19 patients|| Usual care and treatment for all patients, including those with COVID-19||Identify context-relevant core services. Shift service delivery platforms. Consider reduction in elective patient encounters, including elective surgical procedures.|| Mass critical care (e.g. open ICU for cohorted patients).
|-
| Care areas expansion|| No requirements for expansion|| Designate 10 beds per suspected COVID-19 case|| Expand COVID-19 patient care areas by a factor of 35 ||Expand COVID-19 patient care areas by a factor of 58
|}

=== Quantification of need ===
At this time there are various parallel initiatives aimed at forecasting the South African epidemic, quantifying the projected need for facilities, and a shortfall in existing capacity. At this time, there is no consensus on this. This section will be updated as further data becomes available.
ACS will prioritise mild to moderately affected COVID-19 patients where basic, targeted medical care will be provided. Should patients’ needs evolve, requiring escalation of care, then the transfer of patients from ACS sites to conventional sites of care will be needed as a matter of course, bringing with it logistical challenges and risks. In the event that the conventional hospital platform is unable to cope, ACS will have pressure to provide care for severe and critical patients, and finally for patients with comorbidity and special requirements, such as paediatrics, persons living with HIV (PLHIV), TB patients and pregnant women. The following pragmatic approach, aligned with the WHO recommended strategic approach, is suggested.
*ACS should preferably be identified with space for expansion.
*The set-up should be done so that levels of care can be upgraded to higher levels of uncomplicated care.
*A secondary upgrade for more diverse package of care may become necessary.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Strategic Approach''' ==
According to WHO, clinical interventions must be put into place immediately and then scaled up according to the epidemiologic profile.
[[File:COVID-19 Resource allocation.png|none|thumb|600px|right|WHO Strategic approach to clinical care]] 
Under this declared state of disaster, the clinical care strategy which cannot be accommodated within existing facilities, can, on a temporary basis be hosted in ACS:
*Within and around existing healthcare facilities, via reconfiguration and/or augmentation.
*In existing non-healthcare buildings suitable for repurposing, such as universities, hotels and conference centres, warehouses, gyms, hostels etc.
*On open fields, including paved parking areas with rapidly constructed, dismountable structures, such as modular tented structures or using rapid modular construction techniques. 

ACS will provide isolation, general (non-acute) care for patients with mild to moderate symptoms and as required, acute care for patients with severe symptoms. Containing confirmed-case patients from general population. Confirmed-case patients can be housed together en masse, while presumptive-case patients must be individually quarantined.
As shown in the WHO Strategic approach to clinical care, the WHO recommends a range of services to meet patient need (''Citation needed''). General (non-acute) care ACS model is designed for minimal acuity patients requiring minimal activities of daily living support (e.g. COVID-positive with minimal symptoms or require <2L of oxygen). Acute care ACS model is designed for higher acuity patients requiring closer monitoring or respiratory support (e.g. COVID-positive with pneumonia or respiratory distress requiring ventilator support). Paediatric patients are to be accommodated in separate wards, where strictly controlled visitation may be allowed. 
As a preliminary estimate, the following ratios of service is proposed:
[[File:COVID Ratios of Service.png|none|thumb|600px|center|COVID Ratios of Service]]

{| class="wikitable"
|-
! '''Case severity, risk factors<ref group="Notes"> Test suspect COVID-19 cases according to diagnostic strategy</ref><ref group="Note"> Known risk factors for severe COVID-19: age over 60 years, hypertension, diabetes, cardiovascular disease, chronic respiratory disease, immunocompromising conditions.</ref>''' !! '''Recommendations'''
|-
|Mild || Patient should be instructed to self-isolate and contact COVID-19 information line for advice on testing
and referral.
|-
|Moderate, with no risk factors ||Test suspected COVID-19 cases according to diagnostic strategy. Isolation/ cohorting in:
* Health facilities, if resources allow;
* Community facilities (e.g. stadiums, gymnasiums, hotels) with access to rapid health advice
(i.e. adjacent COVID-19 designated health post/EMT-type 1, telemedicine)
*Self-isolation at home according to National guidance
|-
| Moderate, with risk factors || Patient should be instructed to self-isolate and call COVID-19 hotline for emergency referral as soon as possible
|-
|Severe || Hospitalization for isolation (or cohorting) and inpatient treatment.
|-
|Critical|| Hospitalization for isolation (or cohorting) and inpatient treatment.
|}

=== Notes and References: ===

<references group = "Note" />
<references />

== '''Typology Dictates (Case Studies)''' ==
[[File:NHS Nightingale Hospital London.png|thumb|NHS Nightingale Hospital London <ref name="NHS Nightingale Hospital London">Coronavirus: Building NHS Nightingale Hospital London, 2020 [https://www.bbc.com/news/in-pictures-52092253 https://www.bbc.com/news]</ref>, ]]
To meet the requirements set out in this guidance, prospective “host” sites should be carefully evaluated. The type of “host” site selected will strongly influence or dictate the choice of ACS service model.

No site is likely to meet all requirements and recommendations set out in this document. Adaptations and compromises will be necessary. Services should be provided on site where it is pragmatic to do so, for example where similar services are provided. Outsourcing can also be practical/feasible for some services, such as laboratory services, catering and laundry, provided suitable logistical arrangements can be made.

Some typological responses and service models are set out in precedent examples, shown below. The examples demonstrate that a variety of host settings are workable, provided that the appropriate utility can be contrived. Other than in metroplitan areas, co-location of ACS on the premises of, or adjacent to existing halthcare facilities will often be preferable because this is where intensivists and specialist clinical staffing will be available, and support services may be well established. Nevertheless, augmenting capacity at existing facilities should take into account current workloads and capacity to ensure that the COVID-19 surge disrupts normal service provision as little as possible, including continuity of care for patients with chronic conditions and TB and HIV patients. 

*'''[[Infrastructure Guidance for COVID-19/Alternate Care Sites/Case Studies|SARS ACS Precedents and Case Studies can be found here]] '''

=== Notes and References ===
<references />

== '''ACS Infrastructure Planning''' ==

=== '''Establishing a team''' ===
A planning team should be formalised to establish the minimum planning and operational requirements for the ACS and to liaise with the local community. The team should include individuals with expertise in the following areas (ideally with knowledge of healthcare delivery under emergency conditions):
*Disaster response / emergency management coordination,
*Clinical care and staffing,
*Infection Prevention and Control practitioners must be involved in all stages of planning, commissioning, in-use, and decommissioning of the facility
*Facility set-up, operations and management,
*Security,
*Transport (patient, staff),
*Engineering and project management,
*Procurement and coordination of supplies, equipment and pharmaceuticals, and
*Community liaison to ensure that concerns of the adjacent population on understood an addressed.
It is important to ensure compliance with health, safety and building regulations, by ensuring the involvement of relevant local authorities. Stakeholder engagement should be formally documented. Concerns and grievances should be systematically addressed.

=== '''Structural integrity and operational responsibility''' ===

'''Structural modifications:''' ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered. 

'''Competent person:''' All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed. 

'''Asset responsibility:''' Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented. 

'''Integrity and responsibility'''

'''Structural modifications''': ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered.

'''Competent person''': All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed.

'''Asset responsibility''': Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented.

'''Decommissioning''': Decommissioning of the facility shall be assigned to the competent person discussed above. All residual structures upon decommissioning shall comply with the National Building Regulations. Upon decommissioning, removal of equipment shall be the responsibility of the owner. An infection prevention and control practitioner should be engaged in the decommissioning phase to oversee terminal cleaning and disinfection of equipment and premises.

'''Closure''': Once all patients can be safely discharged or transported back to existing facilities for continued care and there are no ongoing healthcare surge capacity needs, the ACS can be closed. Shut down of an ACS will require decommissioning, identification of new homes or storage for equipment, and termination of ongoing contracts or arrangements. Shut down should be expedited so that the facility can quickly be returned to the control of the existing owners and returned to its usual function.

Action checklist items for ACS closure should include, but not be limited to, the following:
*conduct a site walk-through with the facility owner when shutdown activities are completed to ensure that terminal cleaning and disinfection of supplies and premises, removal of equipment and supplies, and other surge closure activities have been completed to the owner’s satisfaction.
*perform medical records storage procedures.

== '''Site Selection''' ==
When selecting a site, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital can be utilised to determine whether the site is suitable for a 100, 1000 or 2000 bed facility, as required. The following indicative minimum site sizes are needed:
*100 Bed ACS/ hospital conversion, requires ± 4 300 m2
*1000 Bed ACS/ hospital conversion, requires ± 17 600 m2
Evaluation should be done by examining plans (if available), satellite images, drone images, scans and by physical inspection (walkabout). A comprehensive photographic survey should be undertaken and retained for record purposes on the site inspection. This will serve as an audit record and may assist in returning the site to its original function on ACS decommissioning and closure. When scrutinising documents and conducting site inspections to confirm the suitability of a site to host an ACS, the following criteria should be taken into account.
=== Criteria ===
*Affordability (costs, including operational costs known and budget identified),
*Sufficient physical space and capacity to house the immediate need, with the potential to accommodate physical space requirements. For example, open site should not be sloping,
*Legal rights and encumbrances, including renewal opportunity,
*Good access to highway and main roads,
*Well secured perimeter and limited controlled access points,
*Proximity to other hospitals and care sites,
*Accessibility for key staff and public transport,
*Good vehicular access around the site to set up temporary equipment such as back-up generators,
*Free from clear and present danger,
*Outside attenuation zones, floodplains,
*Outside high wind zones,
*Structure in good repair,
*Effective onsite facilities management team who understand how systems work,
*Potential for expansion, if required,
*Access to sufficient capacity for
**potable water,
**adequate sewage,
**telephone,
**internet access with sufficient bandwidth,
**electricity,
*A zone for cleaning, disinfection, and decontamination of equipment at least 15 metres away from occupied areas with access to water, a hard impervious surface and drying areas in the sun, with runoff discharge into the sewer and not into marine ecosystems or the environment. Include area for cleaning and storage of cleaning equipment.
*Likelihood of acceptance of hosting an ACS by the adjacent and local community

=== Desirable ===
*Durable, cleanable surfaces,
*Large open spaces that can be converted to accommodate temporary structures,
*Good ventilation,
*On-site kitchen and laundry,
*Housekeeping staff (chemical and equipment storage, lockers, rest facility, administration office),
*Space conducive for staff respite area and locker rooms,
*Amenities with universal access,
*Fire protection safety and equipment,
*Elevator access for patients if the building has more than one floor,
*Capacity for expansion, and
*Accessible to at least two roadways to provide continued access in the event that one roadway becomes blocked on inaccessible.

== '''Infection Prevention and Control''' ==
General guidance for COVID-19 [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|Infection Prevention and Control]] can be accessed [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|here]] 

Infection prevention and control in the context of COVID-19 should respond to transmission routes of primary concern for the pathogen of interest (droplet and contact transmission, and management of risk waste) as well as infection risk of a general nature (water and sewerage, airborne transmission – under high TB/HIV burden, and general waste).
In addition to satisfying [https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html standard precautions for all patient care], transmission-based precautions should focus on three pillars: exposure reduction by spatial configuration, operational strategies, and personal protection.
=== Transmission-based precautions ===
'''Droplet and contact spread''': Transmission of SARS-CoV-2 virus occurs via droplet and contact spread. The virus has been shown to persist on surfaces for extended periods of time and is known to be efficient at infecting people. 

'''Medical waste and linen:''' As SARS-CoV-02 is carried in body fluids and faecal matter, disposal of contaminated items (tissues) and cleaning regimes (spaces, garments, linen) should be accommodated carefully in the workflow design and infrastructure provision. A site-specific waste management plan should be formulated in accordance with a site-specific waste management plan with reference to SANS 10248. 

'''Airborne transmission:''' Under exceptional circumstances, the risk of airborne transmission arises for SARS-CoV-2, as detailed below.
{| class="wikitable"
|-
!Airborne Transmission Risk Factors
|-
|
As SARS-CoV-2 is not considered airborne, respiratory protection against airborne transmission is not considered necessary, except where aerosolisation of particles may be a risk.
According to the CDC
*tracheal intubation,
*non-invasive ventilation,
*tracheotomy,
*cardiopulmonary resuscitation, or
*manual ventilation before intubation and bronchoscopy.
According to doctors in the field also when performing
*COVID-19 diagnostic sampling as patients can be induced to cough and sneeze.
*Suspected or confirmed comorbidity of TB is not an additional risk where correct COVID-19 PPE is applied.

|}
South Africa has a high prevalence of TB and HIV, and therefore, although the risk of COVID-19 transmission via the airborne route is not paramount, there is a high likelihood that undiagnosed TB infectious patients may present at the ACS for treatment. TB triage may be challenging in the ACS as there are symptoms in common (coughing) with COVID-19. This country-specific risk is taken into account in this guidance

=== Additional precautions ===
'''Water and sewerage contamination:''' The International Water Association [[Infrastructure Guidance for COVID-19/Alternate Care Sites/COVID-19 A Water Professionals Perspective|concluded]] that water and sewerage contamination is not considered to be a key risk factor for COVID-19. The panel expressed concern for “how waste and specifically wastewater (medical) would be handled by places (e.g., hostels, hotels) that are used to serve as interim COVID-19 quarantine or testing facilities or accommodation ([ACS]. These are places other than hospitals that are used in the interim for such purposes and do not usually handle wastewater from medical settings. Such facilities should be monitored carefully.” 

== '''Spatial strategies for infection prevention and control''' ==

=== Restricted access and zone control ===
The site will be arranged to establish clear zoning, with a clear restricted zone protocol and access protection. Zones should be deemed to be "contaminated" or "uncontaminated" with clear transition areas between them.

; Contaminated zones
: (also known as "dirty areas") are areas occupied by COVID-19 infected persons, PUIs, equipment, materials and supplies which have come into contact with such persons without yet undergoing a decontamination procedure. These areas will include patient ward areas and ablutions, patient admissions (including ambulance drop-off) and the associated clinical areas. Staff rest and dining facilities should be outside the contaminated zone. Limited stock for immediate use should be kept in the contaminated zone. Layout designs should consolidate contaminated zones as far as reasonable, and avoid uncontaminated zones as islands in contaminated zones.

; Uncontaminated zones
: (also known as "clean areas") are areas not generally occupied by PUIs or confirmed COVID-19 infected persons. Equipment, materials and supplies in these areas have not yet come into contact with contaminated zones or have undergone a decontamination procedure. These will include clinical management planning rooms, stock rooms, bulk stores, pharmacy, laboratory areas, kitchen and laundry.

; Transition zones
: (also known as intermediate zone) are the spaces through which transfer of people and goods from uncontaminated to decontaminated zones, and vice versa, occur. Materials from the contaminated zone should be decontaminated or contained in the transition zone. The transfer of goods and persons should be highly ritualised and, as far as possible, traffic across transition zones should be minimised. Transition areas should be strategically located to serve this function. Separation of in-going and out-going transfer of goods and persons is preferable. Transition areas include ambulance, trolley decontamination, CSSD, laundry and waste bagging areas, patient locker area and staff change areas with spaces for donning and doffing of PPE.

=== Site layout and master-planning ===
Spatial configuration and layout can ensure unnecessary cross-over of function is avoided. This entails the systematic separation of functions and the managed transition between activities to facilitate consistency of care, an orderly, efficient work environment, less waste and reduced risk for improved outcomes. To achieve this, functional relationships should first be considered at the site level before being considered at the building level. 

<gallery mode=packed heights=300px style="text-align:left">
Layout for a SARS facility, clustering functions with minimised cross-over.png|center|thumb|Layout for a SARS facility, clustering functions with minimised cross-over <ref name="Layout1">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Layout_for_a_Patient_cohorting_strategy.png|center|thumb|Layout for a Patient cohorting strategy <ref name="Layout3">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Tygerberg Hospital virus triage unit site layout.png|center|thumb|Tygerberg Hospital virus triage unit site layout <ref name="Western Cape Provincial Government, 2020a">Western Cape Provincial Government, 2020 a</ref>
</gallery>

The WHO's Clustering Layout <ref name="Layout1"/> and Tygerberg Hospital virus triage unit<ref name="Western Cape Provincial Government, 2020a"/> show worked examples of building and site layouts, which are configured with these principles, respectively. '''Cohorting''' is defined as clustering patients with similar or compatible clinical needs together for risk reduction, acuity, efficiency and quality management, as illustrated in WHO's Cohorting Layout <ref name="Layout3"/>

=== Workflow ===
Within individual functional zones, the workflow activities can be arranged to proceed from clean procedures to contaminated procedures. In the example below, the staff arrival, PPE donning, doffing and patient flows are worked to have controlled interaction and minimised cross-over

<gallery mode=packed heights=400px >
ACS HCW Flow.png |ACS Health Care Worker Flow
COVID-19 Workflow in small unit.png |COVID-19 Workflow in Small Testing Unit <ref name="Western Cape Provincial Government, 2020b>Western Cape Provincial Government, 2020 b</ref>
COVID-19 Workflow in large unit.png |COVID-19 Workflow in Large Testing Unit <ref name="Western Cape Provincial Government, 2020b"/>
</gallery>

As far as possible, a single direction flow of clean to dirty is recommended for all processes: support services, supply and waste.
The Small ACS unit workflow diagram<ref name="Western Cape Provincial Government, 2020b"/> illustrates the recommended separation of access and exit, separate waiting seats, for persons who may be COVID-19 infected. Separate spaces are provided for donning and doffing PPE. Staff change areas are provided.

In the Large ACS unit workflow diagram <ref name="Western Cape Provincial Government, 2020b"/>, there is a clear separation between staff areas and patient areas. Waiting seats are set far apart to reduce transmission risk. Staff change rooms are provided near the point of entry to the facility for staff to change from street clothes into medical work clothes. To prevent work clothes worn inside the facility from contaminating street clothes, these are kept in separate lockers. A step-over barrier from dirty to clean sides of the change room is helpful to enforce a mind-set of avoiding cross-contamination. Bins for contaminated garments are to be provided in change rooms. Shower facilities are to be provided for staff.

== '''Operational Strategies''' ==
=== Cleaning, disinfection and decontamination ===
Surface and substrate specification, and detailing of all areas should, as far as possible, allow for frequent:
*Cleaning with detergent and water.
*Disinfection with 75% alcohol solution (metal surfaces).
*[https://en.wikipedia.org/wiki/Sodium_hypochlorite Sodium hypochlorite] (1,000 ppm)/ Household bleach.
*Disinfectants listed on the EPA List N<ref>The United States Environmental Protection Agency, [https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 List N: Disinfectants for Use Against SARS-CoV-2 (Last Visited 2020) ]</ref> (for non-critical environmental cleaning).
*High-intensity ultraviolet surface disinfection (UV-C).
*Decontamination and sterilisation of clinical equipment.

=== Goods and waste management ===
Remove any unnecessary furniture, equipment and paraphernalia from all patient care and clinical areas. Provide a clear, secure space for waste management. Any potentially infectious waste materials generated at the ACS should be considered and treated as medical waste (health care risk waste). The applicable legislation is:
*[https://www.gov.za/sites/default/files/gcis_document/201409/35405gen452.pdf The National and Provincial Health Care Risk Waste Management Regulations].
*[https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf National Department of Health COVID-19 Environmental Health Guidelines.]<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>
Waste disposal bins should be positioned near the exit inside each patient rooms or wards to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another patient in the same room.

=== Materials and finishes ===
Floor materials must be:
*Level,
*Free of dust and oil,
*Impervious and smooth,
*Slip-resistant in wet areas (e.g. patient ablutions).
Smooth, cement screed floors are acceptable. Where hosting facilities have carpeted areas, a risk assessment of factors such as durability, hygiene and decontamination needs to be conducted. In cases where the acceptance of carpeted flooring is contradicted (but other factors make it a compelling option), temporary floor finishes or covering can be investigated.

== '''Personal protection''' ==
=== Hand sanitation ===
Where wash-hand basins are not provided, clinical wash-hand basins should be installed, at the minimum rate of provision of one wash-hand basin per 5 beds. Clinical wash-hand basins (see figure below) have a variety of features not present in standard wash-hand basins, which are preferable for infection prevention and control. Where standard wash-hand basins are provided, an upgrade is not necessary. In all cases, there should be no surfaces and no clutter, equipment or supplies in the vicinity of wash-hand basins, including surgical gloves.
<gallery mode=packed heights=400px>
Clinical hand wash basin.png|Handwash Basin <ref>de Jager 2020</ref>
Portable Wash-hand Basin.png|Portable wash hand basins can be provided in ACS <ref name="BDPa">BDP 2020, NHS nightingale instruction manual, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf</ref>
</gallery>

Where wash-hand basins are not available, portable units can be used, as shown above<ref name="BDPa"/>. Mounted brackets for hand sanitisers are to be provided for every two beds, preferably mounted near the foot rather than the head of the bed and at all common touch points such as entry points at ablution facilities, linen room, sluice, storerooms, medicine rooms/cupboards, near refrigerators, telephones, light switches, at entry/exit doors, etc.

=== Personal protective equipment ===
Donning and doffing points for personal protective equipment, and convenient, safe disposal of consumables to be placed at critical key points when entering patient areas.
----

=== General transmission mitigation ===
==== Water and sanitation ====
To comply with National Building Regulations; Hazardous Biological Agents Regulations and National Department of Health COVID-19 Environmental Health Guidelines<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>.

==== Droplet aerosolisation ====
When designating areas for procedures during which aerosolization and airborne transmission risk is high, the building ventilation must be carefully considered to take into account downstream risks. In particular, consider to where potentially contaminated air, arising from aerosol-generating procedures, is exhausted. In general, air exhausted directly to the outside is diluted and considered safe, unless there are openings to occupied spaces near the exhaust air outlet. 

In the event that potentially occupied spaces will receive partially diluted or undiluted contaminated air, or where this is indeterminate, the aerosolising activity should be designated to an alternate area. In the event that an alternative is not available, some treatment regime (air filtration or air disinfection) is necessary. 

In most naturally ventilated settings, the airflow direction between zones may fluctuate according to the wind direction. Such high-risk spaces should not be adjacent to spaces with high susceptibility rates, such as PUI areas and uncontaminated areas. Contaminated areas should not be directly adjacent to clean areas unless mechanically ventilated. 
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|Guidance on COVID-19 building ventilation design is provided here]].

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Health, Safety and Well-being''' ==
In addition to the infection prevention and control measures discussed above, the following should be provided for health, safety and well-being.
=== General provisions ===
*Minimised and controlled entry and exit points, with suitable control.
*Clearly identified accessible and marked routes for patients, staff, goods and waste.
*Clear designation of restricted zones.
=== Site level provisions ===
*Safe staff parking and arrival of staff via planned and public transport.
*Clearly demarcated parking for people with disabilities.
*Arrival and departure point for patients via public transport, passenger vehicles, and emergency service.
*Limited safe patient parking.
*Supply of goods and removal of waste.

=== Within and between buildings ===
*Entrances with a clear opening width (CoW) of at least 900mm.
*Routes with a minimum width of 2 000mm free of hazards, for example, rubbish bins.
*All clinical, patient and support areas to be accessible by trolley.
'''Ramps''' should be of stable construction, capable of sustaining a mass of 300kg. They should incorporate side lips and the surface should be slip-resistant. Gradients should be as gentle as the circumstances allow. (Recommended maximum 1:20). 
'''Small changes in floor levels''' are not desirable, but where these exist are to be clearly marked with reflective paint/ tape, and lit at night
Elevators between different floors, where patients need access (The recommended minimum lift size for patient trolley/stretcher movement is 1 400mm × 2 400mm, however, this may not be possible). 
'''Pathways''' to be lit at night, where used at night. 
'''Staircases''' must be well-lit at night with non-slip surfaces and secure balustrades. 
'''Doors''', Double doors and automated or push-operated doors to all clinical areas are to be preferred, where these are newly installed or able to be retrofitted. Door closers are to be disabled, where not necessary to reduce touch surfaces. Hand sanitisers to be provided at where high touch common surfaces occur (e.g. wall-mounted at doorways).

=== Signage ===
The appropriate level of information to facilitate legibility, orientation and wayfinding. Minimum standards, signage to be:
*Clearly visible, simple font, font size, contrasting colours, placed in the field of vision
*Washable
*Comprehensive safety signage - fire signage (exits, equipment etc.)
*Restricted areas clearly marked
*Identification signage - each patient space to be allocated a unique number and a whiteboard or perspex sheet for writing the patient’s name
Signs should be posted immediately outside of patient rooms indicating appropriate IPC precautions and required personal protective equipment (PPE).
Signage of a temporary nature can be provided on laminated white A4 sheets attached eye-level. The text should be black sans-serif (for instance Arial) text at least 40point size and centrally positioned on the sheet. Detailed guidance on signage is provided in IUSS Inclusive environments.
=== Safety and security ===
Upon identification of the ACS host site, a team should be convened to conduct a multidisciplinary safety and security analysis. These critical team members need to form the working committee responsible for undertaking the detailed assessment of the existing facility’s security. They should analyse data about the security system’s condition and review existing security concerns or issues that are reasonably likely to become concerns in the near future. The figure below represents a five-zone approach to security, which is a recommended, systematic approach to security.
[[File:Zonal approach to security.png|center|600px|thumb|IUSS Security- Zonal Approach to Security <ref name="IUSS Security">IUSS Hospital design principles - Security [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file]</ref>]]
The security strategy should take into account that whilst clinical services and some logistical and support services will be required 24 hours a day, seven days per week, some support services, logistics services and auxiliary services may only be operational for the minimum periods required to meet demand. These functional elements should be capable of being secured, for example over weekends and at night, as the case may be.
Detailed guidance is available in [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file IUSS Hospital design principles - Security] <ref name="IUSS Security"/>

=== Comfort and dignity ===
Supplemental heating: Patient health and comfort are dependent on, amongst others, maintaining body temperature. The ACS structural technology must be selected to achieve the general indoor environment conditions discussed in a subsequent section for all clinical and occupied areas. As we are moving into South African winter supplemental heating may be required, especially in the evenings, in order to avoid hypothermia. Use of fans, bar, radiator or gas heaters should be prohibited. Unless clinical areas can be maintained above 18 degrees centigrade, patients should each have an infrared heater available, in addition to blankets. Personal/ donated blankets can be considered if they are laundered first and could be destroyed upon discharge.
Mobile screens should be available to provide privacy where necessary (e.g. during consultations or procedures).
<gallery mode = packed heights = 400px>
Bed_Isolator_-Vietnam.png|thumb|Flexible Barrier Isolator<ref>WHO. (2020), Severe Acute Respiratory Infections Treatment Centre. Geneva, Switzerland : WHO- World Health Organization</ref>
ACS Cohort beds.png|ACS Cohort beds.png|thumb|Excel Centre London 04-2020 <ref>Architects' Journal 2020, [https://www.architectsjournal.co.uk/news/nhs-nightingale-bdp-on-the-first-nine-days-converting-the-excel-centre/10046749.article https://www.architectsjournal.co.uk/news]</ref>
</gallery>
Some solutions which address patient privacy and dignity are depicted above.

=== Notes ===
<references/>

== '''Schedule of Accommodation''' ==
Based on clinical needs of the ACS, a schedule of accommodation can be crafted capturing the clinical, clinical, logistical, support and auxiliary services associated with the render of care. When deriving a schedule of accommodation, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital tool can be used. Functions to be accommodated are: 
'''Clinical services''': Triage, rapid assessment of persons entering the facility, to expeditiously identify and render the appropriate service. Admissions and registration. Inpatient accommodation is to be organised according to cohorting principles, discussed above. Testing and diagnostics, including laboratories and x-ray. Safe storage and dispensing of drugs to patients.Offices for clinical administration and clinical planning meeting rooms in the clean zone are needed. 
'''Logistical services:''' Logistical services will entail management of flows of people, goods, services and information to and from the site, as well as within the site. It includes security and communication arrangements. Staff entry, preparations to transition from outside to clinical work environment, including pause areas for relief. Emergency services, visitors. Goods, supplies and storage and waste removal and/ or treatment.
Support services key to the provision of clinical services should be separated so that the risks associated with that particular activity can be managed. 
'''Support services are:'''
*Laboratory services
*Catering
*Laundry
*Environmental cleaning and housekeeping
*CSSD
*Maintenance and cleaning of surrounds, eg. waste areas
*Porters/”runners”, stretchers/wheelchairs
*Mortuary
* Security
Support services can be provided off-site, in which case, safe, secure and efficient transfer and logistical arrangements should be designed. 
'''Auxiliary services:''' Auxiliary services are services which may be provided on or near the ACS site, but which are not directly related to core clinical care. This included overnight accommodation for staff who may not wish to return home to avoid exposing their families, or who need rest between shifts, or for discharged patients awaiting transport home, volunteers who have recovered from SARS-CoV-2.
Limited psychosocial services and allied health services may also be provided on or near ACS for example by approved partners.
Examples of schedules of accommodation for patient and support spaces for a protective isolation ward is available [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedule for COVID-19 Isolation Wards|here]] and mild to severe cases [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedules for COVID-19 Wards for Mild to Severe Cases|here]].

== '''Clinical Services''' ==
=== Triage ===
Confirmed COVID-19 cases and PUIs who are referred from a testing facility or a higher level of care, will enter the facility in a triage area to receive vital screening and initial assessment. They will be registered and admitted to inpatient care. They will be assigned a "ward" or section of the facility - based on disease status and acuity. These are Protective Isolation, the Mild & Moderate ward, or the Critical & Severe wards. Patients should be clustered according to gender. As far as practicable, ablutions for each gender, isolation patients, paediatrics and staff shall be separately provided. Paediatrics patients, if admitted, are to be assigned a dedicated section.
As patients recover or deteriorate, they may be relocated to the appropriate section/ ward.
Once the patient has sufficiently recovered and a negative test result is received they will be appropriately decontaminated and discharged, collecting medication from the dispensary on exit. Patient movement between various sections of the ACS will be restricted as far as possible, with mobile radiology units, in-ward medication dispensing and in-ward food service.

=== Inpatient ACS accommodation ===
Separate spaces for:
*suspected, unconfirmed cases, under observation (PUIs), to be accommodated in isolation facilities (separate rooms, if possible);
*patients with confirmed COVID-19 with mild to moderate disease, not requiring dedicated oxygen therapy;
*patients who require dedicated oxygen therapy;
*patients requiring mechanical ventilation; and
*recovered/ confirmed negative.
==== Protective Isolation Facilities ====
Suspected, unconfirmed cases, under observation – persons under investigation (PUIs) to be accommodated in protective isolation facilities (separate positive-pressure rooms, if possible). PUI are restricted to their rooms. All food and laundry services will be brought to the PUI rooms to reduce interaction and potential contamination. All waste will be collected by facility staff and taken to waste handling areas. Infection prevention and control measures are put in place for the handling of used food utensil and laundry as well as waste collection. PUI areas will have restricted access, including for staff serving other inpatient sections, for confirmed cases.

==== Inpatients accommodation for confirmed COVID-19 ====

Inpatient facilities confirmed positive COVID-19 can be accommodated in large shared ‘wards’ with partitioning between patients. Partitioning between patients is optional. Partitioning is preferable to curtains found in conventional hospitals, as they are more conducive to daily cleaning. If curtains are used, antimicrobial treated fabrics with biocide used to treat the curtains has been tested to international standard EN 14476 and shown to be effective against H1N1 Influenza A Virus (Swine Flu), >99.999% kill rate in 5 minutes and measles morbillivirus, >99.99% kill rate in 5 minutes are preferred. If only separate rooms are available, patient monitoring and surveillance will need to be accommodated. This phase of treatment has a lower area/space requirement compared with PUIs, as cross-infection between patients is less of a concern. Shared ablution facilities are acceptable. It is recommended that, at least, two general accommodation ward areas be provided. 

a) Mild and moderate patients, and 
b) Serious and critical patients. 

The room must have openable windows for natural ventilation if a dedicated positive pressure ventilation system is not available. Ducted ventilation systems shall not be shared between PUI areas and confirmed COVID-19 patient areas. 
[[File:COVID-19 ACS - protective isolation – bed layout.png|thumb|center|800px|ACS - protective isolation – bed layout]]
[[File:COVID-19 ACS – mild-moderate patient bed layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient bed layout]]
[[File:COVID-19 ACS – mild-moderate patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient shared ward layout]]
[[File:COVID-19 ACS – severe-critical patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – severe-critical patient shared ward layout]]

Examples above show bed layout with bed spacing for protective isolation, a mild/moderate patient and a mild/moderate patient shared ward and for a severe/critical patient

=== Patient services ===
Patients in ACS will not generally be ambulatory and will be confined to their room, or cubicle in a bed. In general, domestic beds or hospitality industry (hotel) beds are not suitable for patient care. These should only be used where a hospital-grade bed cannot be sourced, as hospital beds are designed for ease of cleaning and decontamination (for infection prevention and control) and with patient and ergonomics, safety and comfort taken into account (they prevent back injury for nursing staff and can help to prevent bedsores). The higher the specification of bed, the more suitable it is for the higher levels of care. Lockers for patients personal belongings should be provided in the uncontaminated zone (in which case bedside lockers will not be necessary), and it is preferable (where bedside lockers are not provided) for overbed tables to be provided, per bed, if possible. 
The following beds are suitable:
*Repaired and refurbished beds from condemned hospital stocks.
*South African National Standard, SANS 521:2013 Edition 3.5, on Hospital beds and cots ISBN 978-0-626-28830-3.
*Beds listed on the National Treasury (See [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Hospital Bed Specification|specification]]).
The table below details the minimum services required at each patient bed. Details on these services are discussed in a subsequent section of the document.

{| class="wikitable"
|-
! Service/ Capacity!!Triage!!Isolation !!Mild – moderate inpatient!!Severe case wards!!Critical case wards
|-
| Power – 16A 230V Single socket outlet||As needed ||1 per bed||1 per bed||3 per bed||6 per bed
|-
| UPS Power – 16A 230V Single socket outlet ||As needed||1 per bed||1 per bed||1 per bed||2 per bed
|-
| Medical Air<ref group="Note">Mobile units recommended for intermittent use. 3 per 20 beds</ref><ref group="Note">There are some ventilators which have built-in compressors allowing them to function without Medical Air. This is however, not the norm. With Ventilators probably being the most difficult medical device to obtain at present, it would be prudent to rather allow for Medical Air at each bed.</ref> (LP)400kPa||No||Yes||No||Yes||Yes
|-
| Medical O2 -400kPa||Portable/shared||Portable/shared||No||One||Two
|-
| Vacuum-40kPa||No||Portable/shared||Portable/shared||Yes||Yes
|-
| Equipment rail||||||||Yes||Yes
|-
| Upper room UVGI||Optional||Optional||||||Optional
|-
| Examination light||No||No||Yes||Yes||Yes
|-
| Room Ventilation rate||60 L/s per person||10 L/s per person||10 L/s per person||10 L/s per person||12 ACH
|}
'''Notes: '''
<references group="Note" />

Two additional 16A 230V single socket outlets, one two-pin outlet and a worktop should be provided for every 32 beds (or part thereof), for:
*Electrocardiograph (ECG): Could be omitted if monitors have a full 12 lead ECG function.
*Blood gas analyser: Could be omitted if a Lab Services are available.
*Staff cellphone charging.

Example of healthcare technology to be provided for critical care patients is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]. Severe patients may be provided continuous positive airway pressure (CPAP). Emergency trolleys (“crash carts”) are to be provided in patient areas with convenient access to patient beds, out of the passage of corridors and is moved to the patient when needed. 1 crash cart for every 16 patients (or part thereof, with at least one dedicated for PUIs. An example of provisions for a crash cart is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]
==== Patient ablutions ====
[[SARS-CoV-2 is found in faecal matter]], so careful management of patient body fluids is crucial and convenient, practical support for frequent cleaning of ablutions especially shared ablutions is necessary. Dedicated ablutions (toilets and showers) are to be provided for patient use. Toilets and showers should be in separate rooms.
Hand washbasins and or/ hand sanitiser should be provided both inside and outside the toilet room so that patients can wash their hands on the way in and on the way out of the room.
*1 toilet for every 8 persons.
*1 shower for every 8 persons.
*1 disabled ablution for every 8 regular ablutions (or part thereof).
*1 disabled shower for every 8 persons (or part thereof).

Critical and severe patients may be sedated and have a reduced need to access ablutions, ablution facilities proximity and provision can take this factor into account. Showers and wash hand basins should have hot and cold running water. Where possible ablution facilities must have openable windows for natural ventilation, if not possible the bathroom extraction and room ventilation system must be reviewed before admitting patient '''(see [[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|ventilation]]).'''

Portable toilets and showers may be used, provided that suitable hand wash facilities are provided. These will need to be suitably located, preferably in decentralised clusters, so that patients can easily access them without needing to walk very far. Ablutions should be located and designed in such a way as to provide visual and acoustic privacy, dignity and avoid disturbance of other nearby patients when accessing, using or cleaning the ablutions. Separate ablutions are to be provided for PUIs and confirmed patients.

====Makeshift sluice areas ====
In conventional hospital settings, sluice rooms are provided for cleaning and sanitation of soiled equipment, such as bedpans. In a temporary setting, such as an ACS, the establishment of a temporary sluice room may not be practicable, and there may not be facilities for emptying buckets, rinsing equipment etc.. The following is suggested:
Allocate a toilet, hand wash basin, not in splash range and restrict access to it for draining buckets and install a macerator for disposal of disposable bedpans. Electrical, water and waste supply points required as per supplier specification.
==== Dedicated patient treatment areas ====
The following dedicated, private spaces per ward for clinical procedures are recommended:
*Counselling and consulting room (can be shared), as shown in the figure below
[[File:Consulting room example layout.png|400px|thumb|center|Consulting room example layout]]
*Minor procedures room, as per the example provided in the figure below 
[[File:Treatment-minor procedures room example layout.png|400px|thumb|center|Treatment / minor procedures room example layout]]

== '''Logistical Services''' ==
=== Communications ===
Electronic communication should be facilitated in all zones of the ACS by the provision of device charging stations, and wifi.
=== Visitors entry point ===
Visitors are strongly discouraged from entering the ACS.
*In paediatric wards, one parent may be accommodated to visit a patient. In such cases, direct access for the visitor should be provided so that the visitor does not need to pass through the general patient area. Appropriate PPE must be donned before entering the patient area and hand washing/sanitising must be done when exiting the area.
*Non-patients who are accompanying suspected patients to the facility for testing or admission must be accommodated in a well-ventilated, spacious waiting area. Signage in such waiting areas must inform visitors about symptoms, hand hygiene and PPE.
*Hand washing/sanitizing facilities should be provided.

=== Staff areas ===
==== Staff change rooms ====
A minimum of 9m² or 4m² for a single person, increasing by one m² for each additional person is required. The clean (street side) and dirty (contaminated facility side) of the change room should be separated by a step-over barrier.

==== Staff rest areas ====
Staff rest areas within the main facility should be provided with access to kitchenette facilities and staff ablutions.
=== '''Staff auxiliary services''' ===
'''Staff on-call:'''Since staff may be required to work long hours or could be required to be on-call, shared, overnight sleeping facilities can be provided for staff on duty, outside the contaminated area, but in close proximity on the patient areas. An example is set out in the diagram below.
[[File:Example of on-call sleeping area for staff.png|center|600px|thumb|Example of overnight sleeping area for staff]]

'''Staff accommodation:''' It is advisable to provide some staff accommodation for off-duty staff who may not have suitable alternatives, for example homes too far away, transport limitations or the requirement not to expose family members to risk. This should be provided in the vicinity of the ACS, but in a physically separated zone. This amenity can be outsourced.

== '''Support Services''' ==
=== Workflow principle ===
[[File:Linen processing cycle.png|none|thumb|Linen processing cycle <ref>IUSS 2014 [https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department]</ref>]]
Progressive workflow from “dirty” (that is contaminated) to “clean” linen is advisable to reduce the risk of exposure to contaminated materials. The workflow diagram below, showing the progression from the dirty linen receiving area, to the cleaning process, to decontamination and drying, and finally sorting and packing, and storage, illustrates this principle.
=== Laboratory ===
[[File:Example of modular laboratory.png|right|thumb|Example of modular laboratory]]
The WHO recommends the following laboratory diagnostic equipment be accommodated:<ref>WHO 2020, [https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items]</ref>.
<nowiki>• Lab screening test kit
• Lab confirmation test kit
• RT-PCR kit
• Extraction kit
• Cartridges for RT-PCR automatic systems
• Swab and Viral transport medium
</nowiki>
Additional accommodation requirements are:
# Reception counter- receiving specimens
# Testing with perspex/ glass screen
# Receiving/Data capture
# Specimen holding
# Toilet - staff
# Blood storage fridge
Can be provided as a modular laboratory unit as shown in the diagram.
=== Pharmacy ===
The purpose of the pharmacy is to provide medicines needed for inpatient treatment and care.
All medical supplies should be stored in a secure, climate-controlled area in close proximity to the patient treatment area. The pharmacy must have dry, lockable, climate-controlled storage of medications. Most pharmaceuticals are labelled with storage temperatures. The pharmacy should have adequate ventilation through an openable window to prevent humidity from building up in the room. Air-conditioning or mechanical ventilation can be provided, if necessary.

Dispensing areas must be well lit. Worktop in space for stock records and administration. Dispensing counters to have perspex or glass screens to serveries. Social distancing implemented at counter, between pharmacists/assistants and between chairs in waiting area.

Can be provided in a mobile unit.

=== Radiology ===
The purpose of radiology services is to provide chest X-Ray services for COVID-19 diagnostics. In general, CT scans, bucky rooms etc. associated with some radiology equipment require specialised infrastructure and therefore is not suitable for ACS. Radiology services can be provided as a mobile floor standing unit, or containerised unit. Alternative technologies such as Lodox and hand-held ultrasound devices are being investigated as potential options and could be confirmed as suitable for use in due course.
=== Laundry services ===
All dirty linen should be handled for bagging or binning inside the patient room/cohort area. The clean linen stock should be stored conveniently close to clinical areas, in a dedicated clean area in the uncontaminated zone. Used linen should be stored in a designated, safe, lockable holding area while awaiting collection. Interim storage areas for soiled linen at the wards is allowable; this may be in dirty linen/ utility room.
Any clean linen for PUI areas should be handled in spaces physically separate from dirty linen of confirmed patient areas. It may be necessary to completely separate PUI and confirmed patient linen streams. Soiled linen and clean linen bags and bins should be dedicated and not mixed.
Full laundry cleaning and drying services may be provided on-site or outsourced. If laundry cleaning and drying services were already rendered on or for the host site before it is repurposed as an ACS, then a suitability and risk assessment should be conducted to ensure that the volumes of laundry generated and infection prevention and control measures are conducive and modifications made as necessary. A new full laundry service may take time and resources to establish, and in general, will not be established at a host site as a temporary solution. Where the site and circumstances advocate for the design of a new laundry or the upgrade of an existing laundry, the IUSS Laundry Services for Hospitals should be applied.
==== Siting and model selection considerations ====
When an existing laundry is being assessed for use or a new one is being planned the following considerations apply:
* Water and power capacity.
* Ease of access to the ACS’s main corridors and internal transport routes.
* The noise factor of the facility and its impact on nearby patient care departments.
For outsourced departments:
* Delivery areas to allow sufficient space to ensure that vehicles can manoeuvre and park easily at the reception and dispatch bays.
* Access to the ACS service roads and public roads.
==== Functional requirements ====
The most basic equipment needed in a laundry includes washing machines, tumble dryers and ironing machines. Equipment requiring steam is not recommended for a temporary facility. The sizing of the laundry, equipment and engineering services can be modified based on the principles provided in the IUSS Laundry and linen.
=== Catering services ===
Kitchenettes, that is, areas for tea, coffee and snacks, mainly for staff, in staff pause areas are discussed elsewhere in this document.
Catering services (for staff and patients) may be provided on- or off-site. If the ACS is to be established with easy access to a suitable, existing, functional kitchen service (e.g. hotel, military or hospital catering) which can meet the additional demand of the ACS, then this should be used. If there is no suitable facility, catering should be outsourced via a suitable off-site supplier. Only in the event that no feasible or suitable, existing facility or local supplier is available, should a new catering service be established at the ACS. Detailed guidance for the sizing, design and layout of catering services can be found in the IUSS Catering Services for Hospitals.
The kitchen (for on-site catering) or preparation area (for off-site catering) should be located with easy access to the point of delivery and storage of food. Adequate food and equipment storage space must be provided.
It is recommended that patient and staff meals, where provided, be supplied in disposable, containers, suitable for incineration, and that these are disposed of as risk waste immediately after use.
Where off-site catering is used, a suitable area for receiving should be provided. Space will be required for sorting meals for distribution and collecting and storing dirty dishes, washing dirty dishes, if necessary, and disposing of left-over food and disposable containers and utensils. The size of the areas required for this will depend on the number of meals delivered.

=== CSSD ===
The primary function of a Central Sterile Supply Department (CSSD) is to provide an efficient, economic, continuous and quality supply of disinfected and sterilised items, when needed, to all patient-care service points in the ACS, and to receive returned contaminated items for cleaning.
CSSD with limited sterilisation capacity (autoclave) but sufficient disinfection capacity (instrument washing). The layout requires a designated clean and dirty areas with a hard barrier between to avoid cross-over of staff and equipment. Work is unidirectional - flows from dirty – to clean - to sterile areas.
This yields three distinct zones:
1. Receiving and cleaning with pass-through windows
# Dirty receiving with Perspex or glass partitioning
# Dirty utility
# Decontamination and cleaning/wash area with throughput instrument washing
# Trolley wash/Park – external
2. Inspection, assembly and packaging with pass-through windows
# A tabletop autoclave
# Instrument washer
# Clean Packing area
3. Sterile processing, storage and distribution. (Separate issuing area from receiving area) with pass-through windows
# Store -linen and consumables
# Sterile pack store
# Issue - Collection hatch with Perspex or glass partitioning
Must also have a secure, separate receiving area for consumables receiving and storage.
An example of a CSSD unit is shown in Figure 21.T

[[File:An example of a small CSSD facility.png|600px|thumb|none|An example of a small CSSD facility<ref>IUSS 2014, https://www.iussonline.co.za/norms-standards/support-services/24-central-sterile-service-department</ref>]]

To be understood: Quality of services, eg. water (including a source of distilled or ionised water for rinsing of bronchoscopes) and electricity, quality of management, if equipment is appropriate for needs and fit for purpose, what is required of the equipment in the near and far future (relocation?), compliance with S.A. National Standards for CSSD, compatibility of equipment and devices, correct chemicals, maintenance of equipment, training of operators. Although the use of disposable breathing circuits and accessories (masks) should be encouraged, the capacity to disinfect these items if disposable is not available must be considered.

The CSSD must be sized to serve the ACS. Considerations are workload and space requirements. CFSA has extensive [https://www.fidssa.co.za/Content/Images/CFSA_SOP_2018.pdf standard operating procedures] for CSSD.

Workload: Number and type of procedures, number of procedure rooms, eg for bronchoscopy, operating hours, available inventory, volume of work and peak times, degree of mechanization, eg. manual or automated instrument washing, amount of product to be stored – chemicals, barrier wrap, chemical indicators, etc., storage and distribution records, quality records – eg. equipment checks, disposal needs.

Space requirements: Space for separation of clean and dirty, allow for unidirectional movement, allow space to manoeuvre trolleys (queue, pack/unload), reduce lifting and carrying heavy items, reduce awkward movements, allow for tidy work areas. Insufficient space will compromise sterility!

Preference should be given to construction materials and finishes which are suitable for frequent cleaning and tolerant to chemicals, including bleach (sodium hypochlorite). Impermeable flooring, non-slip and smooth washable walls are needed. Joints at walls and floors and coving at wall edge, and exposed drains should be avoided. Worktops should be sealed and should be ergonomically suitable.

Ceiling heights below 2.8m may be vulnerable to damage from humidity Where steam and moisture are generated. Noise – insulation of washer-disinfector and steriliser in technical walls will reduce noise. Lighting: Natural light if possible – windows sealed. High luminance if artificial lighting. Open, slatted shelves for sterile store area. Sinks for manual washing: At least two basins, deep (25cm at least) basins, 91 cm from floor, wide and long enough for the biggest instrument tray or container, water ports for flushing of lumens.

The CSSD space allocation and layout should be determine based on what procedures and which medical devices will be required. A typical [[equipment list is provided here]].

=== Maintenance and cleaning ===
Maintenance and cleaning services must be accommodated with offices located away from clinical areas.

=== Mortuary services ===
The National Department of Health has issued guidance on handling of dead bodies and infectious remains<ref>National Department of Health South Africa, 2020 [https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf]</ref>, which should be applied to ACS. While some guidelines have recommend that bodies of persons who have died from COVID-19 should only be held for a very brief period prior to cremation or treatment for burial<ref>Zhejiang University, 2020 [http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm]</ref>, the WHO holds the view (at the time of writing) that there is no evidence of persons becoming infected from exposure to bodies during normal ceremonial and burial activities. However, appropriate PPE should be used when handling such bodies with additional airborne precautions to be taken during autopsies<ref>WHO, 24 March 2020 [https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf]</ref>.

Either body cabinets or a refrigerated room could be used for body storage.
==== Location and layout of mortuary service ====
It is likely that not all alternative care sites will have a mortuary. Those without a mortuary must have a holding room that is located away from general access areas. This holding room must be suitably sized and conditioned. A recommended room size is 3.5 m x 3.4 m<ref>IUSS Adult Inpatient Services, 2014, [https://www.iussonline.co.za/docman/document/clinical-services/65-adult-inpatent-services-gazetted/file]</ref>
A mortuary should be located so that it is easily accessible to mortuary staff and related service providers and visitors without presenting either aesthetic, emotional or ethical problems for unrelated staff, patients or visitors. It should be separate from the general facility, allowing access for the family to view a body without passing through any potentially contaminated area of the facility. The visitors’ entrance should be external and completely separate from other access points.
Appropriate routes should be designated so that bodies are not moved through public-access areas.
==== Sizing of mortuary ====
The layout and size of a mortuary are largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.
==== Services ====
The following services are required in a mortuary:
* Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.
* Sluicing facilities are to be provided in both the body-preparation and autopsy areas if they are not a common area.
* Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush-fitted stainless steel grids.
* No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.
* The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.
* Anti-backflow devices should be fitted to the water-supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.
* Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.
==== Finishes ====
Wall and floor finishes should be impervious to liquids and easily cleanable.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Environmental Controls''' ==

== '''General Indoor Environment Conditions''' ==

Existing environmental control systems should be modified to suit requirements in the facility. The following issues should be considered:
* Systems should be set to maximise the introduction of fresh air and maintain the pressure regime (see ventilation).
* The following internal temperature range should be maintained 19 - 24oC.
* Cooling systems should be able to cater for projected internal heat gains from people, lighting and equipment. Indicative heat gains in treatment areas are 8W/m2 from people, 15W/m2 from lighting and 3 W/m2 equipment and in critical care areas 16W/m2 from people, 15W/m2 from lighting and 60W/m2 equipment.
*As heat gain can vary widely between items of equipment, heat gain and utilisation rates for equipment should be obtained from the manufacturer to establish this more accurately.

=== Solid waste from ACS ===
According to the National Department of Health COVID-19 Environmental Health Guidelines
“All solid waste from the facility should be regarded as potentially infectious material and therefore appropriate precautions should be taken". The management of healthcare risk waste (HCRW) should follow the correct identification segregation, storage and disposal processes as indicated in SANS 10248-1.

* HCRW is segregated at the point of generation and shall be containerized to minimize the risk of contamination.
* Waste generated from patients in isolation or quarantine in a designated facility health facility is treated as health care risk waste (HCRW) as per SANS 10248-1-2008.
* The HCRW is properly packaged in a sealed, leak and puncture-proof containers/ boxes.
* The HCRW is labelled with the biohazard symbol/ sign and marked “Corona virus or COVID-19”.
* The HCRW is stored separately from other waste generated.
* The collection, transportation, treatment and disposal is provided by only an appointed/ appropriate contractor/ service provider, however, ensure that waste is safely stored until the health care waste management company can pick it up and that the company knows and acknowledges that waste was generated by suspected or confirmed COVID-19.
* The waste management company collecting must ensure that and treated and disposal is conducted at license waste treatment/ disposal facilities .
* All personnel or staff in contact with patients must be geared with appreciate personal protective equipment (PPE’s) at all times to prevent exposure or risk to health.
* Monitoring should be done at such facilities.
* All, bags, bins and boxes must be adequately sealed, as not to leak any fluids, and must be wiped down with 0.05% chlorine solution

Measures developed should consider the following.
* Develop a waste management plan following national guidelines and best practice standards for the disposal of medical waste (WHO, 2020).
* Establish procedures with medical waste service providers to regularly pick up the waste and dispose of this safely.
* Provision should be made for 5kg of solid waste per bed per day and this should be monitored and supplemented where it appears this may be inadequate.
* Ensure that access to waste is secure and controlled, for instance, by using lockable waste 1000l containers kept in a location that can only be accessed by health facility and nominated service delivery staff.
* Vermin control programs must be implemented throughout the site with HCRW collection points prioritised
* Provision for safe cleaning and disinfection of reusable containers should be provided. Cardboard, single-use HCRW boxes are removed from site and incinerated.
* Waste must not be allowed to accumulate or be stored inappropriate or unsecured containers.

== '''Engineering Services''' ==
Engineering services include patient services, ventilation, electrical power, water, medical gases, oxygen, compressed air, vacuum, lighting, and fire safety that support the needs of the patients and medical staff under normal and emergency situations. Good practice standards are provided in:
* IUSS Building Engineering Services<ref name = "IUSSBES">IUSS 2017, [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file]</ref>
* NHS Nightingale Instruction Manual<ref name="BDP2020">BDP 2020, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf]</ref>.
The guidance below draws on these and other manuals and standards. 

=== Building ventilation ===
==== Mechanical ventilation ====
While SARS-CoV-2 RNA has been detected in aerosol form, in experimental mechanical aerosolization studies, it is primarily spread through droplet and contact spread and the potential for airborne transmission is thought to be low.
However, the following advice is provided by ASHRAE regarding HVAC systems in general spaces (not specific to healthcare):
Effective high levels of ventilation must be achieved in the facility. Existing ventilation systems should be tailored to suit internal layouts and requirements and the following measures should be taken.
* Mechanical systems should be set to maximise fresh air supply to the facility. There should be no recirculated air without HEPA filtration or other validated decontamination processes.
* A pressure regime should be established, as shown in figure 2, to 'push' air from clean areas, to dirty areas and then out of the building.
* A clean air supply of over 10 L/s per person should be targeted for odour control.
* Fresh air supply shall not be located near patient beds to avoid drafts in winter.
* Extraction points can be located near patient beds in isolation wards or at a high level in long-stay wards. Short-circuiting of air between high-level supply and extraction is a performance risk in winter.
* Noise from ventilation systems and fans shall be below 45 dBA
* Protected lobbies, internal partitions, door arrangements, fans and extracts should be used to maintain the pressure regime and airflow as indicated in the diagram below.
 

[[File:Ventilation in temporary facilities.png|600px|thumb|none|Ventilation in temporary facilities<ref name="BDP2020"/>]]

==== Natural ventilation ====
The airflow direction between naturally ventilated zones may fluctuate according to the wind direction. This is not of concern within and between contaminated zones where occupants are either protected with mandatory PPE or confirmed to be infected with disease strains similar enough so as not be able to reinfect others. Where levels of occupant susceptibility to an airborne disease is significantly different, the less susceptible areas (such as PUI areas and uncontaminated areas) shall be protected from the naturally ventilated and contaminated areas by mechanical ventilation systems with a capacity sufficient to overcome the expected natural ventilation pressure fluctuations (typically 5-15Pa). Where such mechanical ventilation systems are not feasible or expected wind pressure is too great, zone adjacently must be avoided.

===Ultraviolet germicidal Irradiation===
The application of Ultraviolet Germicidal Irradiation (UVGI) for room air disinfection is well understood and is proven to be effective in the disinfection of microorganisms including M. tuberculosis (TB) in air. UVGI should, therefore, be considered as a valid element in indoor airborne infection control strategy for high volume settings. Studies have demonstrated the importance of good vertical air mixing in the room, and the safety of UVGI application. In areas where UVGI is indicated, the design and development of UVGI systems should be in accordance with the [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]<ref>van Reenen et al,2019 [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]</ref>

=== Electrical power ===
Sufficient and reliable power must be available at the facility for envisaged medical equipment, medical gases, lighting and building ventilation equipment. Power installations for the temporary facility can be divided into three zones as indicated below. These are existing services, the temporary service zone and services in each bay.
The following should be considered by competent engineering professionals.

=== Existing services ===
*Capacity: Evaluate whether sufficient power to accommodate envisaged medical equipment, additional lighting and heating, building ventilation and air conditioning can be provided. If existing capacity is insufficient, investigate if it is possible to route additional power from additional locations/transformers around the site or from adjacent sites.
* Safety: The existing electrical distribution network must be able to supply the required equipment load. If this is insufficient/appears unreliable, identify how this can be supported.
* Resilience: Evaluate back-up power and a UPS capacity against essential services demand. If existing capacity is not sufficient, source and establish temporary service capacity.

=== Temporary service zones ===
*Identify locations for temporary service zones where equipment can be located.
*Ensure that equipment and maintenance access is safe and easy.
*Ensure that all distribution boards, circuit breakers and cables are clearly labelled.
=== Services in each bay ===
*Provide pre-wired power strips/trunking as per bay requirements.
*Check that these include sufficient electrical outlets and service points for envisaged equipment.
*Ensure that trunking will carry required equipment loadings. The IUSS Building Engineering Services Guide can be used to check requirements<ref name = "IUSSBES"/>.

[[File:Layout_of_power_in_a_temporary_installation.png|600px|thumb|none|Layout of power in a temporary installation <ref name="BDP2020"/>]]
----

=== Water ===
Water points are needed for handwashing, showers and cleaning. The following issues need to be taken into account.
==== Supply ====
Onsite cold water storage, dedicated to the domestic water requirements of the facility, should be provided. A minimum usable volume of 500 litres per bed should be available.
Hot water storage and consumption should be confirmed by an engineer, as follows:
*Storage 25 L per bed.
*Consumption 180 L/bed.day W/O laundry; 250L /bed. day W laundry.

==== Handwashing ====
See infection control for clinical wash-hand basins
==== Showers ====
Showers for staff coming off shift should be available. Staff flow routes exiting contaminated treatment areas should pass through gowning and shower areas.
----

=== Medical gases, oxygen and vacuum (suction) ===
Medical gases, oxygen and vacuum services will be required in the facility. Mobile gas supply requires piping between supply and patient and clutter floor space. Preferably used fixed installations for patient rooms/cubicles, if possible.

System capacity and point of use pressures and consumption rates are to be ensured at all points. WHO provides technical guidance on [https://www.who.int/publications-detail/oxygen-sources-and-distribution-for-covid-19-treatment-centres oxygen sources and distribution]. 
[[File:Medical gas service layout.png|6oopx|thumb|Medical gas service layout<ref name="BDP2020"/>]]
The following points should also be taken into account.
* For centrally supplied medical gas and vacuum services, system resilience and availability must be ensured.
* Compressors, tanks, accumulators, VIEs, headers and controllers must be secured from uncontrolled access.
* Where possible, gas piping should be reticulated below floors or in ceilings to ensure protection from tampering, damage and ease of access.
* Where reticulation is within open areas, high-level reticulation with point-of-use droppers is advised. Low-level reticulation within rooms is to be avoided.
* Flexible piping can be used, ensuring it does not present a contamination or fire risk and should comply with local regulations. Special care should be taken with flexible O2 piping, keeping it to a minimum.
* Vacuum piping may be contaminated, where point-of-use filtration and collection systems fail. Precautions should be taken when demounting or disconnecting temporary vacuum lines.
* Ensure that oxygen pipelines are designed to provide sufficient flow to all oxygen points in the facility. In terms of utilities, oxygen and medical air would be required. A temporary vacuum point can be provided by mobile medical vacuum units distributed throughout the unit.
* Mobile medical air supplies should be considered where reaching piped specifications are not feasible. Where flexible hoses are used for oxygen and medical air special precautions need to be taken. Flexible oxygen piping must be chemically safe for O2 use. Where perishable flexible piping is used for medical air, terminal filtration at the point-of-use may be required at point-of-use. Especially for long-term use.
* Electrical and gas services can be reticulated against pipe racks or boards fixed to the bed-heads for head to head bed arrangements.
* Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.
* Gas service outlets to be labelled and colour-coded with 3mm lettering.
* SANS 7396-1 should be used to specify the requirements from design to commissioning of medical gas and vacuum systems.
* Medical gas and vacuum pipelines shall be marked per SANS 7396-1 and ISO 5359, as applicable.
* Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.
* SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.
* Plain-ended copper tubing for low-pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.
* Laboratory gas taps and valves shall be marked as described in SANS 10140-4.

=== Lighting ===
Existing lighting systems may need to be modified to suit the clinical requirements in the facility. High bay lighting presents inadequate colour rendering quality for the accurate detection or easy diagnosis of certain clinical conditions. This needs to be evaluated in the selection of supplementary lighting systems.
*Lighting levels should be provided in line with the indoor lighting levels recommended in the Table 6 of IUSS Building Engineering Services .
*Mobile task lighting systems may be adopted in the serious and critical stay wards to supplement incorrect lighting quality.
*Emergency lighting and illuminated emergency egress signage should be linked to the back-up power system.
*External security lighting in external parking areas and spaces around the building should be enhanced to ensure the security of medical staff who need to change shifts at night.

=== Fire safety ===
A functional fire alarm system should be available to support the patient care setting. Fire is a very real threat due to the possibility of an oxygen-enriched atmosphere developing so ventilation is crucial.
The use of temporary facilities for medical care should note the following fire risks (NHS, 2020):
*Patients may have a very high dependency.
*Areas are not specifically designed for patients and do not meet guidance on fire compartmentation and progressive horizontal evacuation.
*Large numbers of patients supplied with oxygen up to 10 litres per minute.
*Possibility of oxygen concentrations exceeding those generally found in the atmosphere- less risk if effective ventilation or large volume i.e. high ceilings.
* Possibility of storage, in excess of 40 litres, of alcohol-based chemicals (such as hand-rub), necessitating a flammables cabinet on site.
*Staff who may not normally work together .
*Staff who may not be familiar with the area.
*Staff not trained in fire safety, progressive horizontal evacuation or oxygen isolation for the specific area.
These factors should be taken into account in fire risk assessments which should then address significant findings in an action plan. Fire assessments should be undertaken by a qualified person and shared with operations and building management staff within the facility. Measures developed should include:
*An automatic fire detection system
*An emergency egress plans are prepared that include patients who have a very high dependency.
*Signage, notices and lighting are installed and are working effectively.
*Management processes are in place to minimise the risk of fire from ignition sources, fuels and oxygen.
*Staff are trained and a fire safety guide sheet for staff is developed and issued.
*Emergency egress routes are kept clear.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Additional Resources''' ==
=== [[Directory of Service Providers|A Directory of Service Providers can be viewed here]] ===

=='''References'''==
<references />

[[Category:COVID-19| ]]
[[Category:Alternate Care Sites|Alternate Care Sites]]

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[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19|(Return to Top)]] 
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Infrastructure Guidance for COVID-19/Alternate Care Sites

2020-05-08T08:34:07Z

Peta: /* Workflow */

[[Infrastructure Guidance for COVID-19|Return to Infrastructure Guidance for COVID-19]] 

== '''Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19'''==

This guidance work was initiated under the project titled: 
''Reducing Nosocomial and Community-Acquired Tuberculosis by Strengthening the Capacity of the South African Department of Health to Improve Implementation of Infection Control and Waste Management at All Levels of the Health System Under the President's Emergency Plan for AIDS Relief (PEPFAR)'' 

== '''Purpose and Approach''' ==
The global pandemic of COVID-19 caused by the coronavirus, SARS-CoV-2 is likely to result in a surge in need for medical care for Severe Acute Respiratory Syndrome (SARS) in South Africa. Considering the course of the pandemic in other countries, it is anticipated that South African hospitals will not have sufficient capacity to cope with the surge of persons requiring medical attention and that surge capacity via alternate care sites (ACS) will need to be established.
Surge capacity, contemplated here is not the frequent emergency department overcrowding experienced by healthcare facilities (e.g. Friday/Saturday night emergencies) or local casualty emergency that might overcrowd nearby facilities and have little to no impact on the overall healthcare delivery system. It is when a catastrophic event occurs and the affected population seek medical care from existing local healthcare facilities, causing healthcare infrastructure to become exhausted due to excess in demand. During a healthcare surge, the standard of care will shift from focusing on patient-based outcomes to population-based outcomes, and providers should anticipate “a shift to providing care and allocating scarce equipment, supplies and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals.”<ref>[https://asprtracie.hhs.gov/technical-resources/resource/491/altered-standards-of-care-in-mass-casualty-events Health Systems Research Inc., 2005]</ref> 

Surge capacity can be temporarily established in non-traditional environments, such as hotels, exhibition halls, community halls, and as field hospitals, on open spaces. 

In the context of this document, a quarantine site is a facility for patients who do not require continuous professional medical care, while an ACS is defined as a temporary facility that can provide continuous medical care for SARS. This document provides principles and considerations, high-level guidance for minimum requirements and examples for ACS. 

While an extensive set of health facility guidelines does exist<ref>[https://www.iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-servi IUSS Building Engineering Services (2017)]</ref>, these are applicable for conventional facilities and thus include services and guidelines that are not necessarily relevant to the treatment of a novel, highly infectious pathogen, with pandemic effects. Moreover, these do not provide well for the rapid and temporary establishment of facilities. 

In order to formulate high-level guidance, [[as invited by Business for South Africa]], the team reached out to professional industry bodies for inputs, in particular the South African Institute for Architects (SAIA), The Gauteng Institute for Architects (GiFA) [https://www.gifa.org.za/ Gauteng Institute for Architecture] and the [http://www.safhe.co.za/ South African Federation of Hospital Engineering (SAFHE)], by inviting input via a 36-hour research charrette. Relevant historical and contemporary literature was consulted, precedents identified and critically reviewed. An interaction with the team at Wuhan responsible for makeshift hospitals and emergency infectious diseases hospitals, Central-South Architectural Design Institute, was arranged with assistance of the Chinese Embassy. Material from the [[Infrastructure Unit System Support|Infrastructure Unit System Support (IUSS)]], international literature and guidance and input gathered from the broader architectural, engineering and healthcare professional communities was synthesised and moderated by the CSIR team. The draft was reviewed by an expert review panel. 
=== Acknowledgement of contribution ===
The contributions to the initial version of this were gratefully received. [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Acknowledgements|A list of these contributors can be viewed here.]]. 
New contributions are eagerly encouraged along with debate and discussion on the [[Talk:Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites|'''discussion forum.''']] tab above.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Scope and Assumptions''' ==
ACSs as discussed in this document are dedicated, temporary facilities for triage, testing, diagnosis, further referral and treatment of persons:
*suspected of having contracted SARS-CoV-2, (persons under investigation (PUIs)), who are symptomatic and/or are awaiting results,
*or are confirmed to be infected.
ACS will accommodate a variety of clinical, logistical, support and auxiliary services associated with the render of care. ACS will currently not be licensed to provide healthcare services. Since the ACS will operate in a non-healthcare facility, it cannot fully replace a hospital setting and its prime objective is to manage the patient load until the local healthcare system can meet demands. 

=== Exclusions ===
Quarantine facilities are accommodation facilities where a member of the community can remain for the duration of their isolation period. This is typically temporary housing for a cohort of people who do not need intensive medical attention but who cannot stay at home. Patients can take care of themselves and need limited monitoring by medical staff. Quarantine: Containing presumptive-case patients from each other and the general population.
Quarantine facilities – that is for asymptomatic persons who are in the community in self- or imposed isolation, but not displaying symptoms, or who are symptomatic, but are able to safely recover without clinical intervention and do not need continuous medical observation are not considered in this document.

=== Service regime ===
The following assumptions are made with respect to services under consideration.
* Temporary - limited to the part of the pandemic when the “conventional” hospital platform cannot meet demand. To be dismantled, thereafter.
* Uncomplicated, dedicated COVID-19 care is to be prioritised for ACS.
* Patients with comorbidities, paediatrics will be prioritised for conventional facilities, and only accommodated in ACS as a matter of last resort.
* 24 hour, 7 days a week operations. 

=== Assumed mechanism of transmission ===
Transmission of SARS-CoV-2 is understood to be from person to person firstly by [https://en.wikipedia.org/wiki/Transmission_(medicine)#Droplet_infection droplet] transmission, then by the [https://en.wikipedia.org/wiki/Transmission_(medicine)#Direct_contact contact] route and finally via airborne [https://en.wikipedia.org/wiki/Transmission_(medicine)#Airborne_airborne transmission] during or following mechanical aerosolisation. Water transmission risks are minor, occurring in special [https://en.wikipedia.org/wiki/Transmission_(medicine)#Fecal%E2%80%93oral Fecal-oral] circumstances. Reclassification of transmission mechanisms may nullify some of the approaches presented in this guidance. 

=== A call for strategic coordination ===
This document focusses on infrastructure requirements. These provisions are meaningless without staffing, equipping and resourcing. Whilst staffing, equipping and resourcing are not the focus of this document, these are likely to emerge as key constraining features. Resource constraints are likely to become acute during this pandemic. Doctors and nurses are already in critical short supply in South Africa and internationally, and are themselves susceptible to COVID-19 infection. Equipment and consumables are in short supply with heightened global demand, reduced manufacturing capacity and limits in trade flows. This necessitates strategic coordination, proactive planning, options appraisal and prioritisation. 

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Status Quo''' ==
=== Rationale and transmission status ===
According to the [https://en.wikipedia.org/wiki/World_Health_Organization World Health Organisation] (WHO), based on the largest cohort of COVID-19 patients, about 40% of patients with COVID-19 may have mild disease, where treatment is mostly symptomatic and does not require inpatient care. About 40% of patients have moderate disease that may require inpatient care; 15% of patients will have severe disease that requires oxygen therapy or other inpatient interventions, and about 5% have critical disease that requires the patient to receive mechanical ventilation. However, the evolution of the outbreak in some countries has shown a higher proportion of severe and critical cases and the need to rapidly increase surge capacity to prevent rapid exhaustion of biomedical supplies and staff. In some countries, doubling rates of cases every three days has been observed<ref>WHO-2019-nCoV-HCF_operations-2020, [https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331492/WHO-2019-nCoV-HCF_operations-2020.1-eng.pdf]</ref> 

South Africa has a high burden of disease, with a high prevalence of [https://en.wikipedia.org/wiki/HIV/AIDS_in_South_Africa HIV and TB]. Although evidence is yet to emerge of the effect of SARS-CoV-2 on a population with these pre-existing conditions, there is reason to proceed with caution<ref>The Conversation 2020, https://theconversation.com/tb-hiv-and-COVID-19-urgent-questions-as-three-epidemics-collide-134554</ref>. There is a potential direct and indirect benefit of ACS to people living with HIV and TB, as well as to general public health and the health system preservation. 

With the travel lockdown in place, and continued transmission, it appears that South Africa is on the cusp between cluster transmission and community transmission according to WHO’s classification, shown in the [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites#Key_clinical_and_infection_control_activities_for_different_transmission_scenarios_.5B3.5D|table below]], indicating that preparation should include temporary hospital facilities and mass critical care.

==== Key clinical and infection control activities for different transmission scenarios <ref>WHO 2020, [https://apps.who.int/iris/handle/10665/331492 https://apps.who.int/iris/handle/10665/331492]</ref> ====
{| class="wikitable"
|-
! !! '''No Case''' !! '''Sporadic Case''' !! '''Clusters of Cases''' !! '''Community Transmission'''
|-
| Faculty Space, Including for Transmission|| Usual Space. Enhanced Screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards). || More patient care areas re-purposed for COVID-19 within the health system, especially for severe cases || Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Staff|| Usual space. Enhanced screening and triage at all points of first access to the health system|| Dedicated COVID-19 patient care areas within health facility (e.g. infectious disease ward, isolation rooms in emergency or ICU wards)||More patient care areas repurposed for COVID-19 within the health system, especially for severe cases||Expanded care for severe cases in new hospitals or temporary hospital facilities
|-
| Supplies||
*On-hand supplies. Equip wards for COVID-19 treatment.
*Identify essential equipment and supplies, including oxygen.
*Prepare expanded local supply chain
||
*Expanded inventory of supplies with detailed protocols for use.
*Activate expanded local supply chain.
*Prepare national supply chain.
||
*Conservation, adaptation, selected re-use when safe.
*Activate contingency planning and procurement for essential equipment and supplies.
*National supply chain.
*Prepare expanded supply chain at the global level
||
*Activate contingency planning should critical equipment be in short supply.
*Determine allocation of lifesaving resources for HCWs and patients.
*Activate expanded global supply chain
|-
| Standard of Care|| Usual care with enhanced awareness and recognition of immediate needs for first COVID-19 patients|| Usual care and treatment for all patients, including those with COVID-19||Identify context-relevant core services. Shift service delivery platforms. Consider reduction in elective patient encounters, including elective surgical procedures.|| Mass critical care (e.g. open ICU for cohorted patients).
|-
| Care areas expansion|| No requirements for expansion|| Designate 10 beds per suspected COVID-19 case|| Expand COVID-19 patient care areas by a factor of 35 ||Expand COVID-19 patient care areas by a factor of 58
|}

=== Quantification of need ===
At this time there are various parallel initiatives aimed at forecasting the South African epidemic, quantifying the projected need for facilities, and a shortfall in existing capacity. At this time, there is no consensus on this. This section will be updated as further data becomes available.
ACS will prioritise mild to moderately affected COVID-19 patients where basic, targeted medical care will be provided. Should patients’ needs evolve, requiring escalation of care, then the transfer of patients from ACS sites to conventional sites of care will be needed as a matter of course, bringing with it logistical challenges and risks. In the event that the conventional hospital platform is unable to cope, ACS will have pressure to provide care for severe and critical patients, and finally for patients with comorbidity and special requirements, such as paediatrics, persons living with HIV (PLHIV), TB patients and pregnant women. The following pragmatic approach, aligned with the WHO recommended strategic approach, is suggested.
*ACS should preferably be identified with space for expansion.
*The set-up should be done so that levels of care can be upgraded to higher levels of uncomplicated care.
*A secondary upgrade for more diverse package of care may become necessary.

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Strategic Approach''' ==
According to WHO, clinical interventions must be put into place immediately and then scaled up according to the epidemiologic profile.
[[File:COVID-19 Resource allocation.png|none|thumb|600px|right|WHO Strategic approach to clinical care]] 
Under this declared state of disaster, the clinical care strategy which cannot be accommodated within existing facilities, can, on a temporary basis be hosted in ACS:
*Within and around existing healthcare facilities, via reconfiguration and/or augmentation.
*In existing non-healthcare buildings suitable for repurposing, such as universities, hotels and conference centres, warehouses, gyms, hostels etc.
*On open fields, including paved parking areas with rapidly constructed, dismountable structures, such as modular tented structures or using rapid modular construction techniques. 

ACS will provide isolation, general (non-acute) care for patients with mild to moderate symptoms and as required, acute care for patients with severe symptoms. Containing confirmed-case patients from general population. Confirmed-case patients can be housed together en masse, while presumptive-case patients must be individually quarantined.
As shown in the WHO Strategic approach to clinical care, the WHO recommends a range of services to meet patient need (''Citation needed''). General (non-acute) care ACS model is designed for minimal acuity patients requiring minimal activities of daily living support (e.g. COVID-positive with minimal symptoms or require <2L of oxygen). Acute care ACS model is designed for higher acuity patients requiring closer monitoring or respiratory support (e.g. COVID-positive with pneumonia or respiratory distress requiring ventilator support). Paediatric patients are to be accommodated in separate wards, where strictly controlled visitation may be allowed. 
As a preliminary estimate, the following ratios of service is proposed:
[[File:COVID Ratios of Service.png|none|thumb|600px|center|COVID Ratios of Service]]

{| class="wikitable"
|-
! '''Case severity, risk factors<ref group="Notes"> Test suspect COVID-19 cases according to diagnostic strategy</ref><ref group="Note"> Known risk factors for severe COVID-19: age over 60 years, hypertension, diabetes, cardiovascular disease, chronic respiratory disease, immunocompromising conditions.</ref>''' !! '''Recommendations'''
|-
|Mild || Patient should be instructed to self-isolate and contact COVID-19 information line for advice on testing
and referral.
|-
|Moderate, with no risk factors ||Test suspected COVID-19 cases according to diagnostic strategy. Isolation/ cohorting in:
* Health facilities, if resources allow;
* Community facilities (e.g. stadiums, gymnasiums, hotels) with access to rapid health advice
(i.e. adjacent COVID-19 designated health post/EMT-type 1, telemedicine)
*Self-isolation at home according to National guidance
|-
| Moderate, with risk factors || Patient should be instructed to self-isolate and call COVID-19 hotline for emergency referral as soon as possible
|-
|Severe || Hospitalization for isolation (or cohorting) and inpatient treatment.
|-
|Critical|| Hospitalization for isolation (or cohorting) and inpatient treatment.
|}

=== Notes and References: ===

<references group = "Note" />
<references />

== '''Typology Dictates (Case Studies)''' ==
[[File:NHS Nightingale Hospital London.png|thumb|NHS Nightingale Hospital London <ref name="NHS Nightingale Hospital London">Coronavirus: Building NHS Nightingale Hospital London, 2020 [https://www.bbc.com/news/in-pictures-52092253 https://www.bbc.com/news]</ref>, ]]
To meet the requirements set out in this guidance, prospective “host” sites should be carefully evaluated. The type of “host” site selected will strongly influence or dictate the choice of ACS service model.

No site is likely to meet all requirements and recommendations set out in this document. Adaptations and compromises will be necessary. Services should be provided on site where it is pragmatic to do so, for example where similar services are provided. Outsourcing can also be practical/feasible for some services, such as laboratory services, catering and laundry, provided suitable logistical arrangements can be made.

Some typological responses and service models are set out in precedent examples, shown below. The examples demonstrate that a variety of host settings are workable, provided that the appropriate utility can be contrived. Other than in metroplitan areas, co-location of ACS on the premises of, or adjacent to existing halthcare facilities will often be preferable because this is where intensivists and specialist clinical staffing will be available, and support services may be well established. Nevertheless, augmenting capacity at existing facilities should take into account current workloads and capacity to ensure that the COVID-19 surge disrupts normal service provision as little as possible, including continuity of care for patients with chronic conditions and TB and HIV patients. 

*'''[[Infrastructure Guidance for COVID-19/Alternate Care Sites/Case Studies|SARS ACS Precedents and Case Studies can be found here]] '''

=== Notes and References ===
<references />

== '''ACS Infrastructure Planning''' ==

=== '''Establishing a team''' ===
A planning team should be formalised to establish the minimum planning and operational requirements for the ACS and to liaise with the local community. The team should include individuals with expertise in the following areas (ideally with knowledge of healthcare delivery under emergency conditions):
*Disaster response / emergency management coordination,
*Clinical care and staffing,
*Infection Prevention and Control practitioners must be involved in all stages of planning, commissioning, in-use, and decommissioning of the facility
*Facility set-up, operations and management,
*Security,
*Transport (patient, staff),
*Engineering and project management,
*Procurement and coordination of supplies, equipment and pharmaceuticals, and
*Community liaison to ensure that concerns of the adjacent population on understood an addressed.
It is important to ensure compliance with health, safety and building regulations, by ensuring the involvement of relevant local authorities. Stakeholder engagement should be formally documented. Concerns and grievances should be systematically addressed.

=== '''Structural integrity and operational responsibility''' ===

'''Structural modifications:''' ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered. 

'''Competent person:''' All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed. 

'''Asset responsibility:''' Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented. 

'''Integrity and responsibility'''

'''Structural modifications''': ACSs are for temporary use and any modifications necessary for the establishment of the clinical and associated support services should be undertaken with minimum invasiveness to the structure so that restoration to the original function is considered.

'''Competent person''': All structure, water, electricity, fire, gas and infection prevention and control installations, whether temporary or permanent must be designed and installed by competent persons. Any modification to any existing structure must be undertaken with prior knowledge and express approval of a duly appointed competent person (such as a registered professional engineer or architect) who is to take responsibility to ensure structural integrity. Competent persons should be explicitly appraised of the nature of services to be rendered, have access to multi-disciplinary specialist support as required and have professional indemnity insurance covering the scope of work. Competent persons shall ensure that all temporary structures are adequately specified and fastened, and safe for use for the purpose they are installed.

'''Asset responsibility''': Unless otherwise agreed, equipment provided to the ACS, will be presumed to be the property and responsibility of the supplier, (including consumables and maintenance) until duly authorised evidence of asset transfer is documented.

'''Decommissioning''': Decommissioning of the facility shall be assigned to the competent person discussed above. All residual structures upon decommissioning shall comply with the National Building Regulations. Upon decommissioning, removal of equipment shall be the responsibility of the owner. An infection prevention and control practitioner should be engaged in the decommissioning phase to oversee terminal cleaning and disinfection of equipment and premises.

'''Closure''': Once all patients can be safely discharged or transported back to existing facilities for continued care and there are no ongoing healthcare surge capacity needs, the ACS can be closed. Shut down of an ACS will require decommissioning, identification of new homes or storage for equipment, and termination of ongoing contracts or arrangements. Shut down should be expedited so that the facility can quickly be returned to the control of the existing owners and returned to its usual function.

Action checklist items for ACS closure should include, but not be limited to, the following:
*conduct a site walk-through with the facility owner when shutdown activities are completed to ensure that terminal cleaning and disinfection of supplies and premises, removal of equipment and supplies, and other surge closure activities have been completed to the owner’s satisfaction.
*perform medical records storage procedures.

== '''Site Selection''' ==
When selecting a site, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital can be utilised to determine whether the site is suitable for a 100, 1000 or 2000 bed facility, as required. The following indicative minimum site sizes are needed:
*100 Bed ACS/ hospital conversion, requires ± 4 300 m2
*1000 Bed ACS/ hospital conversion, requires ± 17 600 m2
Evaluation should be done by examining plans (if available), satellite images, drone images, scans and by physical inspection (walkabout). A comprehensive photographic survey should be undertaken and retained for record purposes on the site inspection. This will serve as an audit record and may assist in returning the site to its original function on ACS decommissioning and closure. When scrutinising documents and conducting site inspections to confirm the suitability of a site to host an ACS, the following criteria should be taken into account.
=== Criteria ===
*Affordability (costs, including operational costs known and budget identified),
*Sufficient physical space and capacity to house the immediate need, with the potential to accommodate physical space requirements. For example, open site should not be sloping,
*Legal rights and encumbrances, including renewal opportunity,
*Good access to highway and main roads,
*Well secured perimeter and limited controlled access points,
*Proximity to other hospitals and care sites,
*Accessibility for key staff and public transport,
*Good vehicular access around the site to set up temporary equipment such as back-up generators,
*Free from clear and present danger,
*Outside attenuation zones, floodplains,
*Outside high wind zones,
*Structure in good repair,
*Effective onsite facilities management team who understand how systems work,
*Potential for expansion, if required,
*Access to sufficient capacity for
**potable water,
**adequate sewage,
**telephone,
**internet access with sufficient bandwidth,
**electricity,
*A zone for cleaning, disinfection, and decontamination of equipment at least 15 metres away from occupied areas with access to water, a hard impervious surface and drying areas in the sun, with runoff discharge into the sewer and not into marine ecosystems or the environment. Include area for cleaning and storage of cleaning equipment.
*Likelihood of acceptance of hosting an ACS by the adjacent and local community

=== Desirable ===
*Durable, cleanable surfaces,
*Large open spaces that can be converted to accommodate temporary structures,
*Good ventilation,
*On-site kitchen and laundry,
*Housekeeping staff (chemical and equipment storage, lockers, rest facility, administration office),
*Space conducive for staff respite area and locker rooms,
*Amenities with universal access,
*Fire protection safety and equipment,
*Elevator access for patients if the building has more than one floor,
*Capacity for expansion, and
*Accessible to at least two roadways to provide continued access in the event that one roadway becomes blocked on inaccessible.

== '''Infection Prevention and Control''' ==
General guidance for COVID-19 [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|Infection Prevention and Control]] can be accessed [[Infrastructure Guidance for COVID-19/COVID-19 Infection Prevention and Control|here]] 

Infection prevention and control in the context of COVID-19 should respond to transmission routes of primary concern for the pathogen of interest (droplet and contact transmission, and management of risk waste) as well as infection risk of a general nature (water and sewerage, airborne transmission – under high TB/HIV burden, and general waste).
In addition to satisfying [https://www.cdc.gov/infectioncontrol/basics/standard-precautions.html standard precautions for all patient care], transmission-based precautions should focus on three pillars: exposure reduction by spatial configuration, operational strategies, and personal protection.
=== Transmission-based precautions ===
'''Droplet and contact spread''': Transmission of SARS-CoV-2 virus occurs via droplet and contact spread. The virus has been shown to persist on surfaces for extended periods of time and is known to be efficient at infecting people. 

'''Medical waste and linen:''' As SARS-CoV-02 is carried in body fluids and faecal matter, disposal of contaminated items (tissues) and cleaning regimes (spaces, garments, linen) should be accommodated carefully in the workflow design and infrastructure provision. A site-specific waste management plan should be formulated in accordance with a site-specific waste management plan with reference to SANS 10248. 

'''Airborne transmission:''' Under exceptional circumstances, the risk of airborne transmission arises for SARS-CoV-2, as detailed below.
{| class="wikitable"
|-
!Airborne Transmission Risk Factors
|-
|
As SARS-CoV-2 is not considered airborne, respiratory protection against airborne transmission is not considered necessary, except where aerosolisation of particles may be a risk.
According to the CDC
*tracheal intubation,
*non-invasive ventilation,
*tracheotomy,
*cardiopulmonary resuscitation, or
*manual ventilation before intubation and bronchoscopy.
According to doctors in the field also when performing
*COVID-19 diagnostic sampling as patients can be induced to cough and sneeze.
*Suspected or confirmed comorbidity of TB is not an additional risk where correct COVID-19 PPE is applied.

|}
South Africa has a high prevalence of TB and HIV, and therefore, although the risk of COVID-19 transmission via the airborne route is not paramount, there is a high likelihood that undiagnosed TB infectious patients may present at the ACS for treatment. TB triage may be challenging in the ACS as there are symptoms in common (coughing) with COVID-19. This country-specific risk is taken into account in this guidance

=== Additional precautions ===
'''Water and sewerage contamination:''' The International Water Association [[Infrastructure Guidance for COVID-19/Alternate Care Sites/COVID-19 A Water Professionals Perspective|concluded]] that water and sewerage contamination is not considered to be a key risk factor for COVID-19. The panel expressed concern for “how waste and specifically wastewater (medical) would be handled by places (e.g., hostels, hotels) that are used to serve as interim COVID-19 quarantine or testing facilities or accommodation ([ACS]. These are places other than hospitals that are used in the interim for such purposes and do not usually handle wastewater from medical settings. Such facilities should be monitored carefully.” 

== '''Spatial strategies for infection prevention and control''' ==

=== Restricted access and zone control ===
The site will be arranged to establish clear zoning, with a clear restricted zone protocol and access protection. Zones should be deemed to be "contaminated" or "uncontaminated" with clear transition areas between them.

; Contaminated zones
: (also known as "dirty areas") are areas occupied by COVID-19 infected persons, PUIs, equipment, materials and supplies which have come into contact with such persons without yet undergoing a decontamination procedure. These areas will include patient ward areas and ablutions, patient admissions (including ambulance drop-off) and the associated clinical areas. Staff rest and dining facilities should be outside the contaminated zone. Limited stock for immediate use should be kept in the contaminated zone. Layout designs should consolidate contaminated zones as far as reasonable, and avoid uncontaminated zones as islands in contaminated zones.

; Uncontaminated zones
: (also known as "clean areas") are areas not generally occupied by PUIs or confirmed COVID-19 infected persons. Equipment, materials and supplies in these areas have not yet come into contact with contaminated zones or have undergone a decontamination procedure. These will include clinical management planning rooms, stock rooms, bulk stores, pharmacy, laboratory areas, kitchen and laundry.

; Transition zones
: (also known as intermediate zone) are the spaces through which transfer of people and goods from uncontaminated to decontaminated zones, and vice versa, occur. Materials from the contaminated zone should be decontaminated or contained in the transition zone. The transfer of goods and persons should be highly ritualised and, as far as possible, traffic across transition zones should be minimised. Transition areas should be strategically located to serve this function. Separation of in-going and out-going transfer of goods and persons is preferable. Transition areas include ambulance, trolley decontamination, CSSD, laundry and waste bagging areas, patient locker area and staff change areas with spaces for donning and doffing of PPE.

=== Site layout and master-planning ===
Spatial configuration and layout can ensure unnecessary cross-over of function is avoided. This entails the systematic separation of functions and the managed transition between activities to facilitate consistency of care, an orderly, efficient work environment, less waste and reduced risk for improved outcomes. To achieve this, functional relationships should first be considered at the site level before being considered at the building level. 

<gallery mode=packed heights=300px style="text-align:left">
Layout for a SARS facility, clustering functions with minimised cross-over.png|center|thumb|Layout for a SARS facility, clustering functions with minimised cross-over <ref name="Layout1">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Layout_for_a_Patient_cohorting_strategy.png|center|thumb|Layout for a Patient cohorting strategy <ref name="Layout3">WHO, 2020 [https://www.who.int/publications-detail/severe-acute-respiratory-infections-treatment-centre Severe Acute Respiratory Infections Treatment Centre]</ref>
Tygerberg Hospital virus triage unit site layout.png|center|thumb|Tygerberg Hospital virus triage unit site layout <ref name="Western Cape Provincial Government, 2020a">Western Cape Provincial Government, 2020 a</ref>
</gallery>

The WHO's Clustering Layout <ref name="Layout1"/> and Tygerberg Hospital virus triage unit<ref name="Western Cape Provincial Government, 2020a"/> show worked examples of building and site layouts, which are configured with these principles, respectively. '''Cohorting''' is defined as clustering patients with similar or compatible clinical needs together for risk reduction, acuity, efficiency and quality management, as illustrated in WHO's Cohorting Layout <ref name="Layout3"/>

=== Heading text ===
Workflow
Within individual functional zones, the workflow activities can be arranged to proceed from clean procedures to contaminated procedures. In the example below, the staff arrival, PPE donning, doffing and patient flows are worked to have controlled interaction and minimised cross-over

<gallery mode=packed heights=400px >
ACS HCW Flow.png |ACS Health Care Worker Flow
COVID-19 Workflow in small unit.png |COVID-19 Workflow in Small Testing Unit <ref name="Western Cape Provincial Government, 2020b>Western Cape Provincial Government, 2020 b</ref>
COVID-19 Workflow in large unit.png |COVID-19 Workflow in Large Testing Unit <ref name="Western Cape Provincial Government, 2020b"/>
</gallery>

As far as possible, a single direction flow of clean to dirty is recommended for all processes: support services, supply and waste.
The Small ACS unit workflow diagram<ref name="Western Cape Provincial Government, 2020b"/> illustrates the recommended separation of access and exit, separate waiting seats, for persons who may be COVID-19 infected. Separate spaces are provided for donning and doffing PPE. Staff change areas are provided.

In the Large ACS unit workflow diagram <ref name="Western Cape Provincial Government, 2020b"/>, there is a clear separation between staff areas and patient areas. Waiting seats are set far apart to reduce transmission risk. Staff change rooms are provided near the point of entry to the facility for staff to change from street clothes into medical work clothes. To prevent work clothes worn inside the facility from contaminating street clothes, these are kept in separate lockers. A step-over barrier from dirty to clean sides of the change room is helpful to enforce a mind-set of avoiding cross-contamination. Bins for contaminated garments are to be provided in change rooms. Shower facilities are to be provided for staff.

== '''Operational Strategies''' ==
=== Cleaning, disinfection and decontamination ===
Surface and substrate specification, and detailing of all areas should, as far as possible, allow for frequent:
*Cleaning with detergent and water.
*Disinfection with 75% alcohol solution (metal surfaces).
*[https://en.wikipedia.org/wiki/Sodium_hypochlorite Sodium hypochlorite] (1,000 ppm)/ Household bleach.
*Disinfectants listed on the EPA List N<ref>The United States Environmental Protection Agency, [https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2 List N: Disinfectants for Use Against SARS-CoV-2 (Last Visited 2020) ]</ref> (for non-critical environmental cleaning).
*High-intensity ultraviolet surface disinfection (UV-C).
*Decontamination and sterilisation of clinical equipment.

=== Goods and waste management ===
Remove any unnecessary furniture, equipment and paraphernalia from all patient care and clinical areas. Provide a clear, secure space for waste management. Any potentially infectious waste materials generated at the ACS should be considered and treated as medical waste (health care risk waste). The applicable legislation is:
*[https://www.gov.za/sites/default/files/gcis_document/201409/35405gen452.pdf The National and Provincial Health Care Risk Waste Management Regulations].
*[https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf National Department of Health COVID-19 Environmental Health Guidelines.]<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>
Waste disposal bins should be positioned near the exit inside each patient rooms or wards to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another patient in the same room.

=== Materials and finishes ===
Floor materials must be:
*Level,
*Free of dust and oil,
*Impervious and smooth,
*Slip-resistant in wet areas (e.g. patient ablutions).
Smooth, cement screed floors are acceptable. Where hosting facilities have carpeted areas, a risk assessment of factors such as durability, hygiene and decontamination needs to be conducted. In cases where the acceptance of carpeted flooring is contradicted (but other factors make it a compelling option), temporary floor finishes or covering can be investigated.

== '''Personal protection''' ==
=== Hand sanitation ===
Where wash-hand basins are not provided, clinical wash-hand basins should be installed, at the minimum rate of provision of one wash-hand basin per 5 beds. Clinical wash-hand basins (see figure below) have a variety of features not present in standard wash-hand basins, which are preferable for infection prevention and control. Where standard wash-hand basins are provided, an upgrade is not necessary. In all cases, there should be no surfaces and no clutter, equipment or supplies in the vicinity of wash-hand basins, including surgical gloves.
<gallery mode=packed heights=400px>
Clinical hand wash basin.png|Handwash Basin <ref>de Jager 2020</ref>
Portable Wash-hand Basin.png|Portable wash hand basins can be provided in ACS <ref name="BDPa">BDP 2020, NHS nightingale instruction manual, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf</ref>
</gallery>

Where wash-hand basins are not available, portable units can be used, as shown above<ref name="BDPa"/>. Mounted brackets for hand sanitisers are to be provided for every two beds, preferably mounted near the foot rather than the head of the bed and at all common touch points such as entry points at ablution facilities, linen room, sluice, storerooms, medicine rooms/cupboards, near refrigerators, telephones, light switches, at entry/exit doors, etc.

=== Personal protective equipment ===
Donning and doffing points for personal protective equipment, and convenient, safe disposal of consumables to be placed at critical key points when entering patient areas.
----

=== General transmission mitigation ===
==== Water and sanitation ====
To comply with National Building Regulations; Hazardous Biological Agents Regulations and National Department of Health COVID-19 Environmental Health Guidelines<ref name="Environmental Health Guidelines">National Department of Health COVID-19 Environmental Health Guidelines [https://j9z5g3w2.stackpathcdn.com/wp-content/uploads/2020/04/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1-3.pdf]</ref>.

==== Droplet aerosolisation ====
When designating areas for procedures during which aerosolization and airborne transmission risk is high, the building ventilation must be carefully considered to take into account downstream risks. In particular, consider to where potentially contaminated air, arising from aerosol-generating procedures, is exhausted. In general, air exhausted directly to the outside is diluted and considered safe, unless there are openings to occupied spaces near the exhaust air outlet. 

In the event that potentially occupied spaces will receive partially diluted or undiluted contaminated air, or where this is indeterminate, the aerosolising activity should be designated to an alternate area. In the event that an alternative is not available, some treatment regime (air filtration or air disinfection) is necessary. 

In most naturally ventilated settings, the airflow direction between zones may fluctuate according to the wind direction. Such high-risk spaces should not be adjacent to spaces with high susceptibility rates, such as PUI areas and uncontaminated areas. Contaminated areas should not be directly adjacent to clean areas unless mechanically ventilated. 
[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|Guidance on COVID-19 building ventilation design is provided here]].

=== Notes and References: ===
<references group = "Note" />
<references />

== '''Health, Safety and Well-being''' ==
In addition to the infection prevention and control measures discussed above, the following should be provided for health, safety and well-being.
=== General provisions ===
*Minimised and controlled entry and exit points, with suitable control.
*Clearly identified accessible and marked routes for patients, staff, goods and waste.
*Clear designation of restricted zones.
=== Site level provisions ===
*Safe staff parking and arrival of staff via planned and public transport.
*Clearly demarcated parking for people with disabilities.
*Arrival and departure point for patients via public transport, passenger vehicles, and emergency service.
*Limited safe patient parking.
*Supply of goods and removal of waste.

=== Within and between buildings ===
*Entrances with a clear opening width (CoW) of at least 900mm.
*Routes with a minimum width of 2 000mm free of hazards, for example, rubbish bins.
*All clinical, patient and support areas to be accessible by trolley.
'''Ramps''' should be of stable construction, capable of sustaining a mass of 300kg. They should incorporate side lips and the surface should be slip-resistant. Gradients should be as gentle as the circumstances allow. (Recommended maximum 1:20). 
'''Small changes in floor levels''' are not desirable, but where these exist are to be clearly marked with reflective paint/ tape, and lit at night
Elevators between different floors, where patients need access (The recommended minimum lift size for patient trolley/stretcher movement is 1 400mm × 2 400mm, however, this may not be possible). 
'''Pathways''' to be lit at night, where used at night. 
'''Staircases''' must be well-lit at night with non-slip surfaces and secure balustrades. 
'''Doors''', Double doors and automated or push-operated doors to all clinical areas are to be preferred, where these are newly installed or able to be retrofitted. Door closers are to be disabled, where not necessary to reduce touch surfaces. Hand sanitisers to be provided at where high touch common surfaces occur (e.g. wall-mounted at doorways).

=== Signage ===
The appropriate level of information to facilitate legibility, orientation and wayfinding. Minimum standards, signage to be:
*Clearly visible, simple font, font size, contrasting colours, placed in the field of vision
*Washable
*Comprehensive safety signage - fire signage (exits, equipment etc.)
*Restricted areas clearly marked
*Identification signage - each patient space to be allocated a unique number and a whiteboard or perspex sheet for writing the patient’s name
Signs should be posted immediately outside of patient rooms indicating appropriate IPC precautions and required personal protective equipment (PPE).
Signage of a temporary nature can be provided on laminated white A4 sheets attached eye-level. The text should be black sans-serif (for instance Arial) text at least 40point size and centrally positioned on the sheet. Detailed guidance on signage is provided in IUSS Inclusive environments.
=== Safety and security ===
Upon identification of the ACS host site, a team should be convened to conduct a multidisciplinary safety and security analysis. These critical team members need to form the working committee responsible for undertaking the detailed assessment of the existing facility’s security. They should analyse data about the security system’s condition and review existing security concerns or issues that are reasonably likely to become concerns in the near future. The figure below represents a five-zone approach to security, which is a recommended, systematic approach to security.
[[File:Zonal approach to security.png|center|600px|thumb|IUSS Security- Zonal Approach to Security <ref name="IUSS Security">IUSS Hospital design principles - Security [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file]</ref>]]
The security strategy should take into account that whilst clinical services and some logistical and support services will be required 24 hours a day, seven days per week, some support services, logistics services and auxiliary services may only be operational for the minimum periods required to meet demand. These functional elements should be capable of being secured, for example over weekends and at night, as the case may be.
Detailed guidance is available in [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/85-security-gazetted/file IUSS Hospital design principles - Security] <ref name="IUSS Security"/>

=== Comfort and dignity ===
Supplemental heating: Patient health and comfort are dependent on, amongst others, maintaining body temperature. The ACS structural technology must be selected to achieve the general indoor environment conditions discussed in a subsequent section for all clinical and occupied areas. As we are moving into South African winter supplemental heating may be required, especially in the evenings, in order to avoid hypothermia. Use of fans, bar, radiator or gas heaters should be prohibited. Unless clinical areas can be maintained above 18 degrees centigrade, patients should each have an infrared heater available, in addition to blankets. Personal/ donated blankets can be considered if they are laundered first and could be destroyed upon discharge.
Mobile screens should be available to provide privacy where necessary (e.g. during consultations or procedures).
<gallery mode = packed heights = 400px>
Bed_Isolator_-Vietnam.png|thumb|Flexible Barrier Isolator<ref>WHO. (2020), Severe Acute Respiratory Infections Treatment Centre. Geneva, Switzerland : WHO- World Health Organization</ref>
ACS Cohort beds.png|ACS Cohort beds.png|thumb|Excel Centre London 04-2020 <ref>Architects' Journal 2020, [https://www.architectsjournal.co.uk/news/nhs-nightingale-bdp-on-the-first-nine-days-converting-the-excel-centre/10046749.article https://www.architectsjournal.co.uk/news]</ref>
</gallery>
Some solutions which address patient privacy and dignity are depicted above.

=== Notes ===
<references/>

== '''Schedule of Accommodation''' ==
Based on clinical needs of the ACS, a schedule of accommodation can be crafted capturing the clinical, clinical, logistical, support and auxiliary services associated with the render of care. When deriving a schedule of accommodation, the National Department of Health COVID-19 - Guideline Room List for Planning a Temporary Hospital tool can be used. Functions to be accommodated are: 
'''Clinical services''': Triage, rapid assessment of persons entering the facility, to expeditiously identify and render the appropriate service. Admissions and registration. Inpatient accommodation is to be organised according to cohorting principles, discussed above. Testing and diagnostics, including laboratories and x-ray. Safe storage and dispensing of drugs to patients.Offices for clinical administration and clinical planning meeting rooms in the clean zone are needed. 
'''Logistical services:''' Logistical services will entail management of flows of people, goods, services and information to and from the site, as well as within the site. It includes security and communication arrangements. Staff entry, preparations to transition from outside to clinical work environment, including pause areas for relief. Emergency services, visitors. Goods, supplies and storage and waste removal and/ or treatment.
Support services key to the provision of clinical services should be separated so that the risks associated with that particular activity can be managed. 
'''Support services are:'''
*Laboratory services
*Catering
*Laundry
*Environmental cleaning and housekeeping
*CSSD
*Maintenance and cleaning of surrounds, eg. waste areas
*Porters/”runners”, stretchers/wheelchairs
*Mortuary
* Security
Support services can be provided off-site, in which case, safe, secure and efficient transfer and logistical arrangements should be designed. 
'''Auxiliary services:''' Auxiliary services are services which may be provided on or near the ACS site, but which are not directly related to core clinical care. This included overnight accommodation for staff who may not wish to return home to avoid exposing their families, or who need rest between shifts, or for discharged patients awaiting transport home, volunteers who have recovered from SARS-CoV-2.
Limited psychosocial services and allied health services may also be provided on or near ACS for example by approved partners.
Examples of schedules of accommodation for patient and support spaces for a protective isolation ward is available [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedule for COVID-19 Isolation Wards|here]] and mild to severe cases [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Examples of Accommodation Schedules for COVID-19 Wards for Mild to Severe Cases|here]].

== '''Clinical Services''' ==
=== Triage ===
Confirmed COVID-19 cases and PUIs who are referred from a testing facility or a higher level of care, will enter the facility in a triage area to receive vital screening and initial assessment. They will be registered and admitted to inpatient care. They will be assigned a "ward" or section of the facility - based on disease status and acuity. These are Protective Isolation, the Mild & Moderate ward, or the Critical & Severe wards. Patients should be clustered according to gender. As far as practicable, ablutions for each gender, isolation patients, paediatrics and staff shall be separately provided. Paediatrics patients, if admitted, are to be assigned a dedicated section.
As patients recover or deteriorate, they may be relocated to the appropriate section/ ward.
Once the patient has sufficiently recovered and a negative test result is received they will be appropriately decontaminated and discharged, collecting medication from the dispensary on exit. Patient movement between various sections of the ACS will be restricted as far as possible, with mobile radiology units, in-ward medication dispensing and in-ward food service.

=== Inpatient ACS accommodation ===
Separate spaces for:
*suspected, unconfirmed cases, under observation (PUIs), to be accommodated in isolation facilities (separate rooms, if possible);
*patients with confirmed COVID-19 with mild to moderate disease, not requiring dedicated oxygen therapy;
*patients who require dedicated oxygen therapy;
*patients requiring mechanical ventilation; and
*recovered/ confirmed negative.
==== Protective Isolation Facilities ====
Suspected, unconfirmed cases, under observation – persons under investigation (PUIs) to be accommodated in protective isolation facilities (separate positive-pressure rooms, if possible). PUI are restricted to their rooms. All food and laundry services will be brought to the PUI rooms to reduce interaction and potential contamination. All waste will be collected by facility staff and taken to waste handling areas. Infection prevention and control measures are put in place for the handling of used food utensil and laundry as well as waste collection. PUI areas will have restricted access, including for staff serving other inpatient sections, for confirmed cases.

==== Inpatients accommodation for confirmed COVID-19 ====

Inpatient facilities confirmed positive COVID-19 can be accommodated in large shared ‘wards’ with partitioning between patients. Partitioning between patients is optional. Partitioning is preferable to curtains found in conventional hospitals, as they are more conducive to daily cleaning. If curtains are used, antimicrobial treated fabrics with biocide used to treat the curtains has been tested to international standard EN 14476 and shown to be effective against H1N1 Influenza A Virus (Swine Flu), >99.999% kill rate in 5 minutes and measles morbillivirus, >99.99% kill rate in 5 minutes are preferred. If only separate rooms are available, patient monitoring and surveillance will need to be accommodated. This phase of treatment has a lower area/space requirement compared with PUIs, as cross-infection between patients is less of a concern. Shared ablution facilities are acceptable. It is recommended that, at least, two general accommodation ward areas be provided. 

a) Mild and moderate patients, and 
b) Serious and critical patients. 

The room must have openable windows for natural ventilation if a dedicated positive pressure ventilation system is not available. Ducted ventilation systems shall not be shared between PUI areas and confirmed COVID-19 patient areas. 
[[File:COVID-19 ACS - protective isolation – bed layout.png|thumb|center|800px|ACS - protective isolation – bed layout]]
[[File:COVID-19 ACS – mild-moderate patient bed layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient bed layout]]
[[File:COVID-19 ACS – mild-moderate patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – mild-moderate patient shared ward layout]]
[[File:COVID-19 ACS – severe-critical patient shared ward layout.png|thumb|center|800px|COVID-19 ACS – severe-critical patient shared ward layout]]

Examples above show bed layout with bed spacing for protective isolation, a mild/moderate patient and a mild/moderate patient shared ward and for a severe/critical patient

=== Patient services ===
Patients in ACS will not generally be ambulatory and will be confined to their room, or cubicle in a bed. In general, domestic beds or hospitality industry (hotel) beds are not suitable for patient care. These should only be used where a hospital-grade bed cannot be sourced, as hospital beds are designed for ease of cleaning and decontamination (for infection prevention and control) and with patient and ergonomics, safety and comfort taken into account (they prevent back injury for nursing staff and can help to prevent bedsores). The higher the specification of bed, the more suitable it is for the higher levels of care. Lockers for patients personal belongings should be provided in the uncontaminated zone (in which case bedside lockers will not be necessary), and it is preferable (where bedside lockers are not provided) for overbed tables to be provided, per bed, if possible. 
The following beds are suitable:
*Repaired and refurbished beds from condemned hospital stocks.
*South African National Standard, SANS 521:2013 Edition 3.5, on Hospital beds and cots ISBN 978-0-626-28830-3.
*Beds listed on the National Treasury (See [[Infrastructure Guidance for COVID-19/Alternate Care Sites/Hospital Bed Specification|specification]]).
The table below details the minimum services required at each patient bed. Details on these services are discussed in a subsequent section of the document.

{| class="wikitable"
|-
! Service/ Capacity!!Triage!!Isolation !!Mild – moderate inpatient!!Severe case wards!!Critical case wards
|-
| Power – 16A 230V Single socket outlet||As needed ||1 per bed||1 per bed||3 per bed||6 per bed
|-
| UPS Power – 16A 230V Single socket outlet ||As needed||1 per bed||1 per bed||1 per bed||2 per bed
|-
| Medical Air<ref group="Note">Mobile units recommended for intermittent use. 3 per 20 beds</ref><ref group="Note">There are some ventilators which have built-in compressors allowing them to function without Medical Air. This is however, not the norm. With Ventilators probably being the most difficult medical device to obtain at present, it would be prudent to rather allow for Medical Air at each bed.</ref> (LP)400kPa||No||Yes||No||Yes||Yes
|-
| Medical O2 -400kPa||Portable/shared||Portable/shared||No||One||Two
|-
| Vacuum-40kPa||No||Portable/shared||Portable/shared||Yes||Yes
|-
| Equipment rail||||||||Yes||Yes
|-
| Upper room UVGI||Optional||Optional||||||Optional
|-
| Examination light||No||No||Yes||Yes||Yes
|-
| Room Ventilation rate||60 L/s per person||10 L/s per person||10 L/s per person||10 L/s per person||12 ACH
|}
'''Notes: '''
<references group="Note" />

Two additional 16A 230V single socket outlets, one two-pin outlet and a worktop should be provided for every 32 beds (or part thereof), for:
*Electrocardiograph (ECG): Could be omitted if monitors have a full 12 lead ECG function.
*Blood gas analyser: Could be omitted if a Lab Services are available.
*Staff cellphone charging.

Example of healthcare technology to be provided for critical care patients is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]. Severe patients may be provided continuous positive airway pressure (CPAP). Emergency trolleys (“crash carts”) are to be provided in patient areas with convenient access to patient beds, out of the passage of corridors and is moved to the patient when needed. 1 crash cart for every 16 patients (or part thereof, with at least one dedicated for PUIs. An example of provisions for a crash cart is shown in [[Infrastructure_Guidance_for_COVID-19/Alternate_Care_Sites/Example_Healthcare_Technology|'''this schedule''']]
==== Patient ablutions ====
[[SARS-CoV-2 is found in faecal matter]], so careful management of patient body fluids is crucial and convenient, practical support for frequent cleaning of ablutions especially shared ablutions is necessary. Dedicated ablutions (toilets and showers) are to be provided for patient use. Toilets and showers should be in separate rooms.
Hand washbasins and or/ hand sanitiser should be provided both inside and outside the toilet room so that patients can wash their hands on the way in and on the way out of the room.
*1 toilet for every 8 persons.
*1 shower for every 8 persons.
*1 disabled ablution for every 8 regular ablutions (or part thereof).
*1 disabled shower for every 8 persons (or part thereof).

Critical and severe patients may be sedated and have a reduced need to access ablutions, ablution facilities proximity and provision can take this factor into account. Showers and wash hand basins should have hot and cold running water. Where possible ablution facilities must have openable windows for natural ventilation, if not possible the bathroom extraction and room ventilation system must be reviewed before admitting patient '''(see [[Infrastructure Guidance for COVID-19/Alternate Care Sites#Building Ventilation|ventilation]]).'''

Portable toilets and showers may be used, provided that suitable hand wash facilities are provided. These will need to be suitably located, preferably in decentralised clusters, so that patients can easily access them without needing to walk very far. Ablutions should be located and designed in such a way as to provide visual and acoustic privacy, dignity and avoid disturbance of other nearby patients when accessing, using or cleaning the ablutions. Separate ablutions are to be provided for PUIs and confirmed patients.

====Makeshift sluice areas ====
In conventional hospital settings, sluice rooms are provided for cleaning and sanitation of soiled equipment, such as bedpans. In a temporary setting, such as an ACS, the establishment of a temporary sluice room may not be practicable, and there may not be facilities for emptying buckets, rinsing equipment etc.. The following is suggested:
Allocate a toilet, hand wash basin, not in splash range and restrict access to it for draining buckets and install a macerator for disposal of disposable bedpans. Electrical, water and waste supply points required as per supplier specification.
==== Dedicated patient treatment areas ====
The following dedicated, private spaces per ward for clinical procedures are recommended:
*Counselling and consulting room (can be shared), as shown in the figure below
[[File:Consulting room example layout.png|400px|thumb|center|Consulting room example layout]]
*Minor procedures room, as per the example provided in the figure below 
[[File:Treatment-minor procedures room example layout.png|400px|thumb|center|Treatment / minor procedures room example layout]]

== '''Logistical Services''' ==
=== Communications ===
Electronic communication should be facilitated in all zones of the ACS by the provision of device charging stations, and wifi.
=== Visitors entry point ===
Visitors are strongly discouraged from entering the ACS.
*In paediatric wards, one parent may be accommodated to visit a patient. In such cases, direct access for the visitor should be provided so that the visitor does not need to pass through the general patient area. Appropriate PPE must be donned before entering the patient area and hand washing/sanitising must be done when exiting the area.
*Non-patients who are accompanying suspected patients to the facility for testing or admission must be accommodated in a well-ventilated, spacious waiting area. Signage in such waiting areas must inform visitors about symptoms, hand hygiene and PPE.
*Hand washing/sanitizing facilities should be provided.

=== Staff areas ===
==== Staff change rooms ====
A minimum of 9m² or 4m² for a single person, increasing by one m² for each additional person is required. The clean (street side) and dirty (contaminated facility side) of the change room should be separated by a step-over barrier.

==== Staff rest areas ====
Staff rest areas within the main facility should be provided with access to kitchenette facilities and staff ablutions.
=== '''Staff auxiliary services''' ===
'''Staff on-call:'''Since staff may be required to work long hours or could be required to be on-call, shared, overnight sleeping facilities can be provided for staff on duty, outside the contaminated area, but in close proximity on the patient areas. An example is set out in the diagram below.
[[File:Example of on-call sleeping area for staff.png|center|600px|thumb|Example of overnight sleeping area for staff]]

'''Staff accommodation:''' It is advisable to provide some staff accommodation for off-duty staff who may not have suitable alternatives, for example homes too far away, transport limitations or the requirement not to expose family members to risk. This should be provided in the vicinity of the ACS, but in a physically separated zone. This amenity can be outsourced.

== '''Support Services''' ==
=== Workflow principle ===
[[File:Linen processing cycle.png|none|thumb|Linen processing cycle <ref>IUSS 2014 [https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department https://www.iussonline.co.za/norms-standards/support-services/30-laundry-and-linen-department]</ref>]]
Progressive workflow from “dirty” (that is contaminated) to “clean” linen is advisable to reduce the risk of exposure to contaminated materials. The workflow diagram below, showing the progression from the dirty linen receiving area, to the cleaning process, to decontamination and drying, and finally sorting and packing, and storage, illustrates this principle.
=== Laboratory ===
[[File:Example of modular laboratory.png|right|thumb|Example of modular laboratory]]
The WHO recommends the following laboratory diagnostic equipment be accommodated:<ref>WHO 2020, [https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/covid-19-critical-items]</ref>.
<nowiki>• Lab screening test kit
• Lab confirmation test kit
• RT-PCR kit
• Extraction kit
• Cartridges for RT-PCR automatic systems
• Swab and Viral transport medium
</nowiki>
Additional accommodation requirements are:
# Reception counter- receiving specimens
# Testing with perspex/ glass screen
# Receiving/Data capture
# Specimen holding
# Toilet - staff
# Blood storage fridge
Can be provided as a modular laboratory unit as shown in the diagram.
=== Pharmacy ===
The purpose of the pharmacy is to provide medicines needed for inpatient treatment and care.
All medical supplies should be stored in a secure, climate-controlled area in close proximity to the patient treatment area. The pharmacy must have dry, lockable, climate-controlled storage of medications. Most pharmaceuticals are labelled with storage temperatures. The pharmacy should have adequate ventilation through an openable window to prevent humidity from building up in the room. Air-conditioning or mechanical ventilation can be provided, if necessary.

Dispensing areas must be well lit. Worktop in space for stock records and administration. Dispensing counters to have perspex or glass screens to serveries. Social distancing implemented at counter, between pharmacists/assistants and between chairs in waiting area.

Can be provided in a mobile unit.

=== Radiology ===
The purpose of radiology services is to provide chest X-Ray services for COVID-19 diagnostics. In general, CT scans, bucky rooms etc. associated with some radiology equipment require specialised infrastructure and therefore is not suitable for ACS. Radiology services can be provided as a mobile floor standing unit, or containerised unit. Alternative technologies such as Lodox and hand-held ultrasound devices are being investigated as potential options and could be confirmed as suitable for use in due course.
=== Laundry services ===
All dirty linen should be handled for bagging or binning inside the patient room/cohort area. The clean linen stock should be stored conveniently close to clinical areas, in a dedicated clean area in the uncontaminated zone. Used linen should be stored in a designated, safe, lockable holding area while awaiting collection. Interim storage areas for soiled linen at the wards is allowable; this may be in dirty linen/ utility room.
Any clean linen for PUI areas should be handled in spaces physically separate from dirty linen of confirmed patient areas. It may be necessary to completely separate PUI and confirmed patient linen streams. Soiled linen and clean linen bags and bins should be dedicated and not mixed.
Full laundry cleaning and drying services may be provided on-site or outsourced. If laundry cleaning and drying services were already rendered on or for the host site before it is repurposed as an ACS, then a suitability and risk assessment should be conducted to ensure that the volumes of laundry generated and infection prevention and control measures are conducive and modifications made as necessary. A new full laundry service may take time and resources to establish, and in general, will not be established at a host site as a temporary solution. Where the site and circumstances advocate for the design of a new laundry or the upgrade of an existing laundry, the IUSS Laundry Services for Hospitals should be applied.
==== Siting and model selection considerations ====
When an existing laundry is being assessed for use or a new one is being planned the following considerations apply:
* Water and power capacity.
* Ease of access to the ACS’s main corridors and internal transport routes.
* The noise factor of the facility and its impact on nearby patient care departments.
For outsourced departments:
* Delivery areas to allow sufficient space to ensure that vehicles can manoeuvre and park easily at the reception and dispatch bays.
* Access to the ACS service roads and public roads.
==== Functional requirements ====
The most basic equipment needed in a laundry includes washing machines, tumble dryers and ironing machines. Equipment requiring steam is not recommended for a temporary facility. The sizing of the laundry, equipment and engineering services can be modified based on the principles provided in the IUSS Laundry and linen.
=== Catering services ===
Kitchenettes, that is, areas for tea, coffee and snacks, mainly for staff, in staff pause areas are discussed elsewhere in this document.
Catering services (for staff and patients) may be provided on- or off-site. If the ACS is to be established with easy access to a suitable, existing, functional kitchen service (e.g. hotel, military or hospital catering) which can meet the additional demand of the ACS, then this should be used. If there is no suitable facility, catering should be outsourced via a suitable off-site supplier. Only in the event that no feasible or suitable, existing facility or local supplier is available, should a new catering service be established at the ACS. Detailed guidance for the sizing, design and layout of catering services can be found in the IUSS Catering Services for Hospitals.
The kitchen (for on-site catering) or preparation area (for off-site catering) should be located with easy access to the point of delivery and storage of food. Adequate food and equipment storage space must be provided.
It is recommended that patient and staff meals, where provided, be supplied in disposable, containers, suitable for incineration, and that these are disposed of as risk waste immediately after use.
Where off-site catering is used, a suitable area for receiving should be provided. Space will be required for sorting meals for distribution and collecting and storing dirty dishes, washing dirty dishes, if necessary, and disposing of left-over food and disposable containers and utensils. The size of the areas required for this will depend on the number of meals delivered.

=== CSSD ===
The primary function of a Central Sterile Supply Department (CSSD) is to provide an efficient, economic, continuous and quality supply of disinfected and sterilised items, when needed, to all patient-care service points in the ACS, and to receive returned contaminated items for cleaning.
CSSD with limited sterilisation capacity (autoclave) but sufficient disinfection capacity (instrument washing). The layout requires a designated clean and dirty areas with a hard barrier between to avoid cross-over of staff and equipment. Work is unidirectional - flows from dirty – to clean - to sterile areas.
This yields three distinct zones:
1. Receiving and cleaning with pass-through windows
# Dirty receiving with Perspex or glass partitioning
# Dirty utility
# Decontamination and cleaning/wash area with throughput instrument washing
# Trolley wash/Park – external
2. Inspection, assembly and packaging with pass-through windows
# A tabletop autoclave
# Instrument washer
# Clean Packing area
3. Sterile processing, storage and distribution. (Separate issuing area from receiving area) with pass-through windows
# Store -linen and consumables
# Sterile pack store
# Issue - Collection hatch with Perspex or glass partitioning
Must also have a secure, separate receiving area for consumables receiving and storage.
An example of a CSSD unit is shown in Figure 21.T

[[File:An example of a small CSSD facility.png|600px|thumb|none|An example of a small CSSD facility<ref>IUSS 2014, https://www.iussonline.co.za/norms-standards/support-services/24-central-sterile-service-department</ref>]]

To be understood: Quality of services, eg. water (including a source of distilled or ionised water for rinsing of bronchoscopes) and electricity, quality of management, if equipment is appropriate for needs and fit for purpose, what is required of the equipment in the near and far future (relocation?), compliance with S.A. National Standards for CSSD, compatibility of equipment and devices, correct chemicals, maintenance of equipment, training of operators. Although the use of disposable breathing circuits and accessories (masks) should be encouraged, the capacity to disinfect these items if disposable is not available must be considered.

The CSSD must be sized to serve the ACS. Considerations are workload and space requirements. CFSA has extensive [https://www.fidssa.co.za/Content/Images/CFSA_SOP_2018.pdf standard operating procedures] for CSSD.

Workload: Number and type of procedures, number of procedure rooms, eg for bronchoscopy, operating hours, available inventory, volume of work and peak times, degree of mechanization, eg. manual or automated instrument washing, amount of product to be stored – chemicals, barrier wrap, chemical indicators, etc., storage and distribution records, quality records – eg. equipment checks, disposal needs.

Space requirements: Space for separation of clean and dirty, allow for unidirectional movement, allow space to manoeuvre trolleys (queue, pack/unload), reduce lifting and carrying heavy items, reduce awkward movements, allow for tidy work areas. Insufficient space will compromise sterility!

Preference should be given to construction materials and finishes which are suitable for frequent cleaning and tolerant to chemicals, including bleach (sodium hypochlorite). Impermeable flooring, non-slip and smooth washable walls are needed. Joints at walls and floors and coving at wall edge, and exposed drains should be avoided. Worktops should be sealed and should be ergonomically suitable.

Ceiling heights below 2.8m may be vulnerable to damage from humidity Where steam and moisture are generated. Noise – insulation of washer-disinfector and steriliser in technical walls will reduce noise. Lighting: Natural light if possible – windows sealed. High luminance if artificial lighting. Open, slatted shelves for sterile store area. Sinks for manual washing: At least two basins, deep (25cm at least) basins, 91 cm from floor, wide and long enough for the biggest instrument tray or container, water ports for flushing of lumens.

The CSSD space allocation and layout should be determine based on what procedures and which medical devices will be required. A typical [[equipment list is provided here]].

=== Maintenance and cleaning ===
Maintenance and cleaning services must be accommodated with offices located away from clinical areas.

=== Mortuary services ===
The National Department of Health has issued guidance on handling of dead bodies and infectious remains<ref>National Department of Health South Africa, 2020 [https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf https://www.nicd.ac.za/wp-content/uploads/2020/03/COVID-19-ENVIRONMENTAL-HEALTH-GUIDELINE-1.pdf]</ref>, which should be applied to ACS. While some guidelines have recommend that bodies of persons who have died from COVID-19 should only be held for a very brief period prior to cremation or treatment for burial<ref>Zhejiang University, 2020 [http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm http://www.zju.edu.cn/english/2020/0323/c19573a1987520/page.htm]</ref>, the WHO holds the view (at the time of writing) that there is no evidence of persons becoming infected from exposure to bodies during normal ceremonial and burial activities. However, appropriate PPE should be used when handling such bodies with additional airborne precautions to be taken during autopsies<ref>WHO, 24 March 2020 [https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/331538/WHO-COVID-19-lPC_DBMgmt-2020.1-eng.pdf]</ref>.

Either body cabinets or a refrigerated room could be used for body storage.
==== Location and layout of mortuary service ====
It is likely that not all alternative care sites will have a mortuary. Those without a mortuary must have a holding room that is located away from general access areas. This holding room must be suitably sized and conditioned. A recommended room size is 3.5 m x 3.4 m<ref>IUSS Adult Inpatient Services, 2014, [https://www.iussonline.co.za/docman/document/clinical-services/65-adult-inpatent-services-gazetted/file]</ref>
A mortuary should be located so that it is easily accessible to mortuary staff and related service providers and visitors without presenting either aesthetic, emotional or ethical problems for unrelated staff, patients or visitors. It should be separate from the general facility, allowing access for the family to view a body without passing through any potentially contaminated area of the facility. The visitors’ entrance should be external and completely separate from other access points.
Appropriate routes should be designated so that bodies are not moved through public-access areas.
==== Sizing of mortuary ====
The layout and size of a mortuary are largely determined by the number of bodies stored and whether body storage needs to be in cabinets or in refrigerated rooms.
==== Services ====
The following services are required in a mortuary:
* Hygienic floor drains that are resistant to corrosion from blood and chlorine should be provided in all “wet areas” of the mortuary and should be directly connected to the sewer system. These areas include body preparation, autopsy space, etc. These areas require thorough cleaning after every procedure, using large quantities of water and decontaminating and disinfecting chemicals and soaps.
* Sluicing facilities are to be provided in both the body-preparation and autopsy areas if they are not a common area.
* Open floor channels should be avoided. Where this is not possible, these should be covered by durable, flush-fitted stainless steel grids.
* No sewer connections external to the mortuary services should be made to the line between the wet area drains and the main sewer system in order to prevent backflow to other areas.
* The provision of hot and cold water in the facility is imperative, with all basins, sinks, ablution areas and autopsy tables being provided with both.
* Anti-backflow devices should be fitted to the water-supply lines serving mortuary table faucets to prevent backflow should supply water pressure fail.
* Electricity supply to the mortuary – particularly for refrigeration purposes – is to be provided from the essential supply system for the hospital. Alternatively, a back-up generator is to be supplied to allow for the maintenance of required temperatures in the cooling/freezing facilities in the mortuary.
==== Finishes ====
Wall and floor finishes should be impervious to liquids and easily cleanable.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Environmental Controls''' ==

== '''General Indoor Environment Conditions''' ==

Existing environmental control systems should be modified to suit requirements in the facility. The following issues should be considered:
* Systems should be set to maximise the introduction of fresh air and maintain the pressure regime (see ventilation).
* The following internal temperature range should be maintained 19 - 24oC.
* Cooling systems should be able to cater for projected internal heat gains from people, lighting and equipment. Indicative heat gains in treatment areas are 8W/m2 from people, 15W/m2 from lighting and 3 W/m2 equipment and in critical care areas 16W/m2 from people, 15W/m2 from lighting and 60W/m2 equipment.
*As heat gain can vary widely between items of equipment, heat gain and utilisation rates for equipment should be obtained from the manufacturer to establish this more accurately.

=== Solid waste from ACS ===
According to the National Department of Health COVID-19 Environmental Health Guidelines
“All solid waste from the facility should be regarded as potentially infectious material and therefore appropriate precautions should be taken". The management of healthcare risk waste (HCRW) should follow the correct identification segregation, storage and disposal processes as indicated in SANS 10248-1.

* HCRW is segregated at the point of generation and shall be containerized to minimize the risk of contamination.
* Waste generated from patients in isolation or quarantine in a designated facility health facility is treated as health care risk waste (HCRW) as per SANS 10248-1-2008.
* The HCRW is properly packaged in a sealed, leak and puncture-proof containers/ boxes.
* The HCRW is labelled with the biohazard symbol/ sign and marked “Corona virus or COVID-19”.
* The HCRW is stored separately from other waste generated.
* The collection, transportation, treatment and disposal is provided by only an appointed/ appropriate contractor/ service provider, however, ensure that waste is safely stored until the health care waste management company can pick it up and that the company knows and acknowledges that waste was generated by suspected or confirmed COVID-19.
* The waste management company collecting must ensure that and treated and disposal is conducted at license waste treatment/ disposal facilities .
* All personnel or staff in contact with patients must be geared with appreciate personal protective equipment (PPE’s) at all times to prevent exposure or risk to health.
* Monitoring should be done at such facilities.
* All, bags, bins and boxes must be adequately sealed, as not to leak any fluids, and must be wiped down with 0.05% chlorine solution

Measures developed should consider the following.
* Develop a waste management plan following national guidelines and best practice standards for the disposal of medical waste (WHO, 2020).
* Establish procedures with medical waste service providers to regularly pick up the waste and dispose of this safely.
* Provision should be made for 5kg of solid waste per bed per day and this should be monitored and supplemented where it appears this may be inadequate.
* Ensure that access to waste is secure and controlled, for instance, by using lockable waste 1000l containers kept in a location that can only be accessed by health facility and nominated service delivery staff.
* Vermin control programs must be implemented throughout the site with HCRW collection points prioritised
* Provision for safe cleaning and disinfection of reusable containers should be provided. Cardboard, single-use HCRW boxes are removed from site and incinerated.
* Waste must not be allowed to accumulate or be stored inappropriate or unsecured containers.

== '''Engineering Services''' ==
Engineering services include patient services, ventilation, electrical power, water, medical gases, oxygen, compressed air, vacuum, lighting, and fire safety that support the needs of the patients and medical staff under normal and emergency situations. Good practice standards are provided in:
* IUSS Building Engineering Services<ref name = "IUSSBES">IUSS 2017, [https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file https://www.iussonline.co.za/docman/document/healthcare-environment-crosscutting-issues/91-iuss-building-engineering-services-gazetted-1/file]</ref>
* NHS Nightingale Instruction Manual<ref name="BDP2020">BDP 2020, [http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf http://www.bdp.com/globalassets/projects/nhs-nightingale-hospital/nhs-nightingale-instruction-manual.pdf]</ref>.
The guidance below draws on these and other manuals and standards. 

=== Building ventilation ===
==== Mechanical ventilation ====
While SARS-CoV-2 RNA has been detected in aerosol form, in experimental mechanical aerosolization studies, it is primarily spread through droplet and contact spread and the potential for airborne transmission is thought to be low.
However, the following advice is provided by ASHRAE regarding HVAC systems in general spaces (not specific to healthcare):
Effective high levels of ventilation must be achieved in the facility. Existing ventilation systems should be tailored to suit internal layouts and requirements and the following measures should be taken.
* Mechanical systems should be set to maximise fresh air supply to the facility. There should be no recirculated air without HEPA filtration or other validated decontamination processes.
* A pressure regime should be established, as shown in figure 2, to 'push' air from clean areas, to dirty areas and then out of the building.
* A clean air supply of over 10 L/s per person should be targeted for odour control.
* Fresh air supply shall not be located near patient beds to avoid drafts in winter.
* Extraction points can be located near patient beds in isolation wards or at a high level in long-stay wards. Short-circuiting of air between high-level supply and extraction is a performance risk in winter.
* Noise from ventilation systems and fans shall be below 45 dBA
* Protected lobbies, internal partitions, door arrangements, fans and extracts should be used to maintain the pressure regime and airflow as indicated in the diagram below.
 

[[File:Ventilation in temporary facilities.png|600px|thumb|none|Ventilation in temporary facilities<ref name="BDP2020"/>]]

==== Natural ventilation ====
The airflow direction between naturally ventilated zones may fluctuate according to the wind direction. This is not of concern within and between contaminated zones where occupants are either protected with mandatory PPE or confirmed to be infected with disease strains similar enough so as not be able to reinfect others. Where levels of occupant susceptibility to an airborne disease is significantly different, the less susceptible areas (such as PUI areas and uncontaminated areas) shall be protected from the naturally ventilated and contaminated areas by mechanical ventilation systems with a capacity sufficient to overcome the expected natural ventilation pressure fluctuations (typically 5-15Pa). Where such mechanical ventilation systems are not feasible or expected wind pressure is too great, zone adjacently must be avoided.

===Ultraviolet germicidal Irradiation===
The application of Ultraviolet Germicidal Irradiation (UVGI) for room air disinfection is well understood and is proven to be effective in the disinfection of microorganisms including M. tuberculosis (TB) in air. UVGI should, therefore, be considered as a valid element in indoor airborne infection control strategy for high volume settings. Studies have demonstrated the importance of good vertical air mixing in the room, and the safety of UVGI application. In areas where UVGI is indicated, the design and development of UVGI systems should be in accordance with the [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]<ref>van Reenen et al,2019 [https://www.tb-ipcp.co.za/tools-resources/uvgi-documents/national-guidelines-abridged Abridged UVGI guide]</ref>

=== Electrical power ===
Sufficient and reliable power must be available at the facility for envisaged medical equipment, medical gases, lighting and building ventilation equipment. Power installations for the temporary facility can be divided into three zones as indicated below. These are existing services, the temporary service zone and services in each bay.
The following should be considered by competent engineering professionals.

=== Existing services ===
*Capacity: Evaluate whether sufficient power to accommodate envisaged medical equipment, additional lighting and heating, building ventilation and air conditioning can be provided. If existing capacity is insufficient, investigate if it is possible to route additional power from additional locations/transformers around the site or from adjacent sites.
* Safety: The existing electrical distribution network must be able to supply the required equipment load. If this is insufficient/appears unreliable, identify how this can be supported.
* Resilience: Evaluate back-up power and a UPS capacity against essential services demand. If existing capacity is not sufficient, source and establish temporary service capacity.

=== Temporary service zones ===
*Identify locations for temporary service zones where equipment can be located.
*Ensure that equipment and maintenance access is safe and easy.
*Ensure that all distribution boards, circuit breakers and cables are clearly labelled.
=== Services in each bay ===
*Provide pre-wired power strips/trunking as per bay requirements.
*Check that these include sufficient electrical outlets and service points for envisaged equipment.
*Ensure that trunking will carry required equipment loadings. The IUSS Building Engineering Services Guide can be used to check requirements<ref name = "IUSSBES"/>.

[[File:Layout_of_power_in_a_temporary_installation.png|600px|thumb|none|Layout of power in a temporary installation <ref name="BDP2020"/>]]
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=== Water ===
Water points are needed for handwashing, showers and cleaning. The following issues need to be taken into account.
==== Supply ====
Onsite cold water storage, dedicated to the domestic water requirements of the facility, should be provided. A minimum usable volume of 500 litres per bed should be available.
Hot water storage and consumption should be confirmed by an engineer, as follows:
*Storage 25 L per bed.
*Consumption 180 L/bed.day W/O laundry; 250L /bed. day W laundry.

==== Handwashing ====
See infection control for clinical wash-hand basins
==== Showers ====
Showers for staff coming off shift should be available. Staff flow routes exiting contaminated treatment areas should pass through gowning and shower areas.
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=== Medical gases, oxygen and vacuum (suction) ===
Medical gases, oxygen and vacuum services will be required in the facility. Mobile gas supply requires piping between supply and patient and clutter floor space. Preferably used fixed installations for patient rooms/cubicles, if possible.

System capacity and point of use pressures and consumption rates are to be ensured at all points. WHO provides technical guidance on [https://www.who.int/publications-detail/oxygen-sources-and-distribution-for-covid-19-treatment-centres oxygen sources and distribution]. 
[[File:Medical gas service layout.png|6oopx|thumb|Medical gas service layout<ref name="BDP2020"/>]]
The following points should also be taken into account.
* For centrally supplied medical gas and vacuum services, system resilience and availability must be ensured.
* Compressors, tanks, accumulators, VIEs, headers and controllers must be secured from uncontrolled access.
* Where possible, gas piping should be reticulated below floors or in ceilings to ensure protection from tampering, damage and ease of access.
* Where reticulation is within open areas, high-level reticulation with point-of-use droppers is advised. Low-level reticulation within rooms is to be avoided.
* Flexible piping can be used, ensuring it does not present a contamination or fire risk and should comply with local regulations. Special care should be taken with flexible O2 piping, keeping it to a minimum.
* Vacuum piping may be contaminated, where point-of-use filtration and collection systems fail. Precautions should be taken when demounting or disconnecting temporary vacuum lines.
* Ensure that oxygen pipelines are designed to provide sufficient flow to all oxygen points in the facility. In terms of utilities, oxygen and medical air would be required. A temporary vacuum point can be provided by mobile medical vacuum units distributed throughout the unit.
* Mobile medical air supplies should be considered where reaching piped specifications are not feasible. Where flexible hoses are used for oxygen and medical air special precautions need to be taken. Flexible oxygen piping must be chemically safe for O2 use. Where perishable flexible piping is used for medical air, terminal filtration at the point-of-use may be required at point-of-use. Especially for long-term use.
* Electrical and gas services can be reticulated against pipe racks or boards fixed to the bed-heads for head to head bed arrangements.
* Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.
* Gas service outlets to be labelled and colour-coded with 3mm lettering.
* SANS 7396-1 should be used to specify the requirements from design to commissioning of medical gas and vacuum systems.
* Medical gas and vacuum pipelines shall be marked per SANS 7396-1 and ISO 5359, as applicable.
* Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.
* SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.
* Plain-ended copper tubing for low-pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.
* Laboratory gas taps and valves shall be marked as described in SANS 10140-4.

=== Lighting ===
Existing lighting systems may need to be modified to suit the clinical requirements in the facility. High bay lighting presents inadequate colour rendering quality for the accurate detection or easy diagnosis of certain clinical conditions. This needs to be evaluated in the selection of supplementary lighting systems.
*Lighting levels should be provided in line with the indoor lighting levels recommended in the Table 6 of IUSS Building Engineering Services .
*Mobile task lighting systems may be adopted in the serious and critical stay wards to supplement incorrect lighting quality.
*Emergency lighting and illuminated emergency egress signage should be linked to the back-up power system.
*External security lighting in external parking areas and spaces around the building should be enhanced to ensure the security of medical staff who need to change shifts at night.

=== Fire safety ===
A functional fire alarm system should be available to support the patient care setting. Fire is a very real threat due to the possibility of an oxygen-enriched atmosphere developing so ventilation is crucial.
The use of temporary facilities for medical care should note the following fire risks (NHS, 2020):
*Patients may have a very high dependency.
*Areas are not specifically designed for patients and do not meet guidance on fire compartmentation and progressive horizontal evacuation.
*Large numbers of patients supplied with oxygen up to 10 litres per minute.
*Possibility of oxygen concentrations exceeding those generally found in the atmosphere- less risk if effective ventilation or large volume i.e. high ceilings.
* Possibility of storage, in excess of 40 litres, of alcohol-based chemicals (such as hand-rub), necessitating a flammables cabinet on site.
*Staff who may not normally work together .
*Staff who may not be familiar with the area.
*Staff not trained in fire safety, progressive horizontal evacuation or oxygen isolation for the specific area.
These factors should be taken into account in fire risk assessments which should then address significant findings in an action plan. Fire assessments should be undertaken by a qualified person and shared with operations and building management staff within the facility. Measures developed should include:
*An automatic fire detection system
*An emergency egress plans are prepared that include patients who have a very high dependency.
*Signage, notices and lighting are installed and are working effectively.
*Management processes are in place to minimise the risk of fire from ignition sources, fuels and oxygen.
*Staff are trained and a fire safety guide sheet for staff is developed and issued.
*Emergency egress routes are kept clear.

=== Notes and References: ===
<references group="Notes" />
<references />

== '''Additional Resources''' ==
=== [[Directory of Service Providers|A Directory of Service Providers can be viewed here]] ===

=='''References'''==
<references />

[[Category:COVID-19| ]]
[[Category:Alternate Care Sites|Alternate Care Sites]]

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[[Infrastructure Guidance for COVID-19/Alternate Care Sites#Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19|(Return to Top)]] 
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