Infrastructure Guidance for COVID-19/Alternate Care Sites

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Infrastructure Guidance for COVID-19/Alternate Care Sites2

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 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.”

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 , 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, 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) Gauteng Institute for Architecture and the 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. Material from the 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. Contributors and reviewers are acknowledged in text.

Scope and Assumptions

ACSs as discussed in this document are dedicated, temporary facilities for triage, testing, diagnosis, on-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. Patients with comorbidities, paediatrics will be prioritised for conventional facilities.
• 24 hour, 7 days a week operations.
  

Assumed mechanism of transmission

Transmission of SARS-CoV-2 is understood to be preferentially transmitted from person to person by the contact and droplet routes with opportunistic airborne transmission and negligible water transmission risks in special 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.

Status quo

Rationale and transmission status

According to the 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

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.

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 table below, indicating that preparation should include temporary hospital facilities and mass critical care.

Key clinical and infection control activities for different transmission scenarios

	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. ACS will attend to mild to moderately affected COVID-19 patients where basic, targeted medical care will be provided. Should patients’ needs evolve, requiring escalation of care, then 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. The following pragmatic approach, aligned with the WHO recommended strategic approach, is suggested.

• ACS should be preferably identified with space for expansion. The set-up should be done so that levels of care can be upgraded to higher levels of care.
• This guidance makes the assumption that only uncomplicated COVID-19 cases will be treated at an ACS, entailing that patients with comorbidities, and paediatrics will be referred to conventional facilities. Depending on epidemic trajectory, it may be necessary to expand services to include a greater range of clinical services at ACS.

Strategic approach

WHO Strategic approach to clinical care

According to WHO, clinical interventions must be put into place immediately, and then scaled up according to the epidemiologic profile.

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 WHO Strategic approach to clinical care, WHO recommends a range of services to meet patient need. 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:

COVID Ratios of Service

Case severity, risk factors	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.

^* Known risk factors for severe COVID-19: age over 60 years, hypertension, diabetes, cardiovascular disease, chronic respiratory

disease, immunocompromising conditions.
Note: Probable cases should be retested immediately.

Typology dictates

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 model 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.

SARS ACS precedents

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Site type:

Existing Hospital

Response: Minor Adaptive Reuse

Service Model: Clustered Cohort

Examples:

Sung-Shan Military Hospital Taipei
Conversion of existing non-isolation buildings to isolation wards for treatment of SARS patients. Steps for conversion and implementation described. Nosocomial infection rate 0.6% ascribed to non-compliance with procedures. Infrastructure steps taken: 1) Clear buildings of people & equipment. 2) Fans (commercial grade 3X1m blaes, 65W, 60Hz) above each window. 3) plug doors to create negative pressure relative to corridor (0.028-0.07 water gauge in rooms to 0.0 in corridors.) 4) Close stairways between floors. 5) creating three zones at the ground floor for entry A: clean zone for changing and administration; B: Intermediate zone for removing inner layer of PPE, showering; C: contaminated zone for removing outer layer of PPE; 6) cleaning regime described. 7) Patient transport described; 8) Treatment of SARS patients and handling of equipment described: Interesting: Centralize facilities to better control / train health care workers and nosocomial infections.

Response: Augmentation

Service Model: Mass ICU

Examples:

Richmond University Medical Center in West Brighton
A medical tent is stationed outside Richmond University Medical Center in West Brighton

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  A medical tent is stationed outside Richmond University Medical Center in West Brighton

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Site type:

Existing Hotel

Response: Minor Adaptive Reuse

Service Model: Obligate - Cellular/ single room

Examples:

Theory Only

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  Triage Assessment Scenario

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  Covid19 Hotel Facility.png

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Site type:

Conference Centre

Response: Repurposing

Service Model: Mass ICU

Examples:

NHS Nightingale Hospital, London, Javits Center, New York, Los Angeles Convention Centre

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  NHS Nightingale Hospital London

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  Javits Center temporary hospital patient space

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  Los Angeles Convention Center overflow management study

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Site type:

Open Field

Response: Modular Construction

Service Model: Cellular / Single Room

Examples:

Volumetric Building Companies (VBC) Philadelphia (Linear format), MAII – USA (Clustered configuration)

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  Floor plan for modular self-contained care unit

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  MAII - USA (Clustered Configuration)

Response: Repurposed Shipping Containers

Service Model: Mass ICU

Examples:

CURA, Milan

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  Axonometric diagram of how the containers would be laid out

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  Visualisation of CURA concept

Response: Tented Construction

Service Model: Mass ICU or Triage

Examples:

Central Park, New York Brescia, Lombardy, Italy

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  A temporary hospital in Central Park's East Meadow

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  Medical personnel work inside a triage tent at a hospital in Brescia, Italy on March 13.Photographer: Francesca Volpi/Bloomberg

Notes:

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. 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.

ACS Planning 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,
• 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.

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 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 solutions should not be sloping,
• Legal rights and encumbrances, including renewal opportunity,
• Free from clear and present danger,
• Outside attenuation zones, floodplains,
• Outside high wind zones,
• Structure in good repair,
• Access to sufficient capacity for
  • potable water,
  • adequate drainage,
  • telephone and/or wifi,
  • electricity, and
• Likelihood of acceptance of hosting an ACS by the adjacent and local community

Desirable

• 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.
• Capacity for expansion.
• 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 Infection Prevention and Control can be accessed here

Infection prevention and control in the context of COVID-19 should respond to transmission routes of primary concern for the pathogen of interest (contact and droplet 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 standard precautions, transmission-based precautions should focus on three pillars: exposure reduction by spatial configuration, operational strategies, and personal protection.

Transmission-based precautions

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.

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.

Standard precautions

Water and sewerage contamination: The International Water Association 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.”

Airborne transmission: Under exceptional circumstances the risk of airborne transmission arises for SARS-CoV-2, as detailed below.

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 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

Restricted access and zone control

The site will be arranged to ensure clear zoning, with a clear restricted zone protocol and access protection. The public will not be permitted to visit patients at ACS sites, unless they are the parent of minor, or care giver of the elderly. Access to wards will be strictly controlled, and full donning and doffing will be required by the visitor.

Site layout and master-planning

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 building level.

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  Layout for a SARS facility, clustering functions with minimised cross-over

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  Layout for a Patient cohorting strategy

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  Tygerberg Hospital virus triage unit site layout

The WHO's Clustering Layout and Tygerberg Hospital virus triage unit 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

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

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  ACS Health Care Worker Flow

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  COVID-19 Workflow in Small Unit

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  COVID-19 Workflow in Large Unit

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 illustrates the recommended separation of access and exit, separate waiting seats, for persons who may be COVID19 infected. Separate spaces are provided for donning and doffing PPE. Staff change areas are provided.

In the Large ACS unit workflow diagram , 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 be 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 bench 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).
• Sodium hypochlorite (1,000 ppm)/ Household bleach.
• Disinfectants listed on the EPA List N (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:

• The National and Provincial Health Care Risk Waste Management Regulations.
• National Department of Health COVID-19 Environmental Health Guidelines.

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-handbasin per 5 beds. Clinical wash-hand basins (see Figure 8) 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 in the vicinity of wash-hand basins, including surgical gloves.

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  Handwash Basin

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  Portable wash hand basins can be provided in ACS

Where wash-hand basins are not available, portable units can be used, as shown above. Mounting brackets for hand sanitisers are to be provided for every two beds and at all common touchpoints such as entry points at ablution facilities, light switches, 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.

Airborne precautions

When designating areas for activities during which airborne transmission risk is high, the ventilation must be carefully considered to take into account downstream risk. In particular, the question should be raised as to where potentially contaminated air, arising from aerosol-generating procedures, is exhausted to. 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 naturally ventilated settings, the patterns of the exhaust of air to spaces (adjacent or in close proximity) may vary according to uncontrollable externalities (e.g. wind direction), and therefore is indeterminate. 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. 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 Abridged UVGI guide.

Detailed guidance on COVID-19 ventilation design is provided here.

2.5 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, and gas 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 and closure

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. 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 decontamination and removal of 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 walkthrough with the facility owner when shutdown activities are completed to ensure that removal of equipment and supplies, cleaning and other surge closure activities have been completed to the owner’s satisfaction.
• perform medical records storage procedures.

2.7 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 wellbeing.

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.
• Supply of goods and removal of waste.
• Limited safe visitor parking.

Within and between buildings

• Clear entrances.
• Routes free of all 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. Unless physical structure prohibits, 2-metre clear access ways.
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 thresholds where high touch common surfaces (e.g. door handles are unavoidable) within the patient areas.

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.

IUSS Security- Zonal Approach to Security

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 IUSS Hospital design principles - 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). <be>

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  Flexible Barrier Isolator

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  Excel Centre London 04-2020

Some solutions which address patient privacy and dignity are depicted above.

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.
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 and associated with that particular activity can be managed.
Support services are:

• Laboratory services
• Catering
• Laundry
• CSSD
• Maintenance and cleaning
• Mortuary

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 here and 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-based on disease status and acuity to 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 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 is preferable to curtains found in conventional hospitals, as they are more conducive to daily cleaning. If only separate rooms are available, patient monitoring and surveillance will need to be accommodated. This phase of treatment has the lowest area/space requirement, 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 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.

ACS - protective isolation – bed layout

COVID-19 ACS – mild-moderate patient bed layout

COVID-19 ACS – mild-moderate patient shared ward layout

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 ideal 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.
The following 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 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.

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 (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:

Two additional 16A 230V single socket outlets 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.

Example of healthcare technology to be provided for critical care patients is shown in Appendix F. Severe patients may be provided 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 this schedule

Patient ablutions

As discussed in Appendix B, 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 ventilation, if not possible the bathroom extraction and room ventilation system must be reviewed before admitting patient (see 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

Consulting room example layout

• Minor procedures room, as per the example provided in the figure below
  

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.

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 bench.

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 overnight:Since staff may be required to work long hours or could be required to be on-call, overnight sleeping facilities can be provided for staff, outside the clinical area, but in close proximity on the ACS site. An example is set out in the diagram below.

Example of overnight sleeping area for staff

Support services

Workflow principle

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.

Linen processing cycle

Laboratory

Example of modular laboratory

The WHO recommends the following laboratory diagnostic equipment be accommodated:.

• Lab screening test kit 
• Lab confirmation test kit
• RT-PCR kit
• Extraction kit 
• Cartridges for RT-PCR automatic systems
• Swab and Viral transport medium

Additional accommodation requirements are:

1. Reception counter- receiving specimens
2. Testing with perspex/ glass screen
3. Receiving/Data capture
4. Specimen holding
5. Toilet - staff
6. Blood storage fridge

Can be provided as a mobile unit as shown in the diagram.