Infrastructure Guidance for COVID-19/Alternate Care Sites

Infrastructure Minimum Guidelines for Alternate Care Sites for COVID-19

This guidance work was initiated under 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 outbreak of Covid-19 in South Africa is likely to result in a surge in need for medical care. 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 isolation sites and alternate care sites (ACS) will need to be established. These can be established in non-traditional environments, such as hotels, exhibition/community halls, and temporary field hospitals. An isolation site is a facility for patients who do not require medical care, while an ACS is defined as a temporary facility that can provide medical care for Severe Acute Respiratory Syndrome (the degree of care will depend on the need). This document provides principles and considerations, high level guidance for minimum requirements and examples. While an extensive set of health facility guidelines does exist (see http://www.iuss.co.za), these are applicable for conventional facilities and thus include services and guidelines that are not necessarily relevant to the treatment of Covid-19, specifically, nor for the rapid and temporary establishment of facilities. The CSIR responded rapidly to the invitation extended by BSA, to formulate high-level guidance through consultation and research. 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) and the South African Federation of Hospital Engineering (SAFHE), by inviting input via a 36 hour research charette. Relevant historical and contemporary literature was consulted, precedents identified and critically reviewed. Material from the 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. Contributors and reviewers are acknowledged in text.

Scope and assumptions

ACSs as discussed in this document are dedicated, temporary facilities for identification 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. Pediatric patients are to be accommodated in separate wards, where strictly controlled visitation may be allowed.

Exclusions:

Quarantine facilities - for asymptomatic persons who are in self- or imposed isolation, but not displaying symptoms, or who are symptomatic, but are able to safely recover without clinical intervention 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. Patients with comorbidities, paediatrics will be prioritised for conventional facilities. 24 hour, 7 days a week operations Assumed mechanism of transmission transmission is understood to be preferentially by the contact and droplet routes with opportunistic airborne transmission in special circumstances. reclassification of transmission mechanisms may nullify some of the approaches presented in this guidance.

Rationale and transmission status

According to the 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 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. South Africa has a high burden of disease, with a high prevalence of 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. There is 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. It appears that South Africa is on the cusp between cluster transmission and community transmission according to WHO’s classification, indicating that preparation can include temporary hospital facilities and mass critical care.

	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 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 patientcare 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 shortfall in existing capacity. At this time, there is no consensus on this. This section will be updated as further data becomes available.

Strategic approach

According to WHO, for clinical care, six major interventions must be put into place immediately, and then scaled up according to epidemiologic scenarios.

To meet the requirements set out above, prospective sites should be evaluated, by scrutinizing plans, satellite images and by physical inspection (walkabout). Expanded, services, UNDER THESE UNUSUAL CONDITIONS (State of Disaster), could, on a temporary basis be hosted:

• 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 etc.
• On open fields, including paved parking areas with rapidly constructed, dismantlable structures, such as modular tented structures or using rapid modular construction techniques.

The type of “host” site selected will strongly influence or dictate the choice of ACS service model. Some typological responses and service model are set out below in precedent examples.

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Example	Example	Example
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No site is likely to meet all requirements and recommendations set out in this document, Adaptations and compromises will be necessary. The examples set out above demonstrate that a variety of host settings are workable, provided that the appropriate utility can be contrived. Ideally all services should be provided on site. However, the use of off-site services is not unconventional and may be practical/feasible for temporary sites, provided suitable procedures are followed. It should be noted that the key limitations are to be found in resource constraints (staff, equipment, funding), and therefore coordinated options appraisal and prioritisation is needed.