Rethinking best practices for the design and operation of health care facilities in light of the COVID-19 pandemic
Submitted by Tetra Tech
Dominick DeRobertis joined Tetra Tech’s High Performance Buildings Group in 2000, becoming a senior vice president and director of health care in 2007. He has more than 25 years of experience in a wide variety of project types, including hospitals, educational facilities, museums, office buildings, hotels, residential buildings, tenant interiors, and retail. His noteworthy health care projects include the new Bellevue Hospital Center Ambulatory Care Facility and new diagnostic and treatment facility for Kings County Hospital in New York; the Cleveland Clinic Lou Ruvo Center for Brain Health in Nevada; and the American Hospital Dubai. In the educational realm, he has led projects for The New School University Center in New York, the University of Michigan’s Ross School of Business, and several projects for the New York City School Construction Authority.
Dominick is a licensed engineer in New York and is certified as a LEED Accredited Professional. He also is a member of the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) and American Society for Healthcare Engineering (ASHE). Dominick holds a Bachelor of Science in Mechanical Engineering from Manhattan College.
Tetra Tech provided engineering design and construction oversight for a rapid response conversion of a closed and partially abandoned medical office building into a 250-bed, non-acute COVID-19 patient care facility in two weeks. How did our team mobilize so quickly?
Mobilization for this project was incredibly fast. I received a call at 8:30 a.m. on a Wednesday early in April to inform me that our team was awarded the project and I was expected at an on-site kickoff meeting with the U.S. Army Corps of Engineers (USACE) and other key participants at 10:00 a.m. The contractor’s management and support team were up and running out of a field office within one day. By Thursday, tradesmen were on-site working. Most offices were closed, and most construction sites were shut down due to the pandemic, making a sizeable workforce immediately available to support the project. I also believe that many team members jumped at the opportunity to work on a project that had a real impact on the community. There was a true sense of comradery throughout the project.
Schedule was the most significant project challenge. The challenges began in our first three days. Day one was dedicated to rapid assessment of the building systems; day two to determining the project requirements for the intended occupancy and the systems and equipment needed to bring the building back to life; and day three to working closely with the contractors to locate and procure replacement equipment.
What was most necessary from a design perspective to ready this space for COVID-19 patients?
A significant effort was needed to create a safe and healthy environment for patients. Many of the 250 beds were to be located in framed patient cubicles built on-site that required normal and emergency power as mandated by code and health care design practice. In total, 30 miles of power wiring was installed throughout the building. We also installed a new diesel generator with automatic transfer switches and switchgear. The building’s ventilation and exhaust systems had to be repaired and rebuilt to achieve a desired level of performance. More than 200 plumbing fixtures were brought in to replace and supplement existing fixtures.
Are there any specific systems that stand out as being particularly innovative given the conditions of the site and the needs of the updated facility?
We looked for opportunities to expedite installation. Two systems that stand out are the nurse call system and the handwashing stations. A conventional hospital nurse call system is a fully wired electronic system that connects call stations from patient beds, bathrooms, and showers to nurses’ stations and other staff locations. It requires a lot of low voltage wiring to interconnect the notification and receiving stations. For this project, we installed a wireless nurse call system that uses a call button on a patient’s lanyard and wireless receiving stations set up at each nurses’ station. In addition, wireless pull cords are provided in every bathroom and shower intended for patient use.
We also added handwashing stations throughout the facility—both for patients and for health care providers—consisting of a sink, a point-of-use electric hot water heater, and an individual ejector pump located under the sink. Using an ejector pump eliminated the need to drill through the floor and connect to the drain piping on the floor below. We used exposed piping from the floor-mounted ejector to the ceiling and connected it to sanitary piping that served the floor above. The key here was speed.
USACE was so impressed with both these systems that they are planning to adopt them into their design standards for rapid-construction facilities of this type.
Another innovative construction approach was used to run wiring from the new emergency generator located in a parking lot about 150 feet from the building to the building’s switchgear room. Rather than trenching and restoring the parking lot, we used underground directional drilling to route the conduit from the generator to the foundation wall. Within a few hours, the underground installation was complete without requiring backfilling and resurfacing the lot.
How did you ensure a safe working environment during the project?
Aside from the typical personal protection gear mandated at construction sites (e.g., hard hats and reflective vests), we faced the challenge of dealing with the COVID-19 virus. New protocols were in place to enforce everyone to wear face masks and gloves, and hand sanitizer stations were set up throughout the project site. Cleaning crews in hazmat gear continuously circulated throughout the site, and elevator use was restricted to four passengers at a time to maintain social distancing. A log was maintained of everyone entering and exiting the site. A total of 24,000 man-hours were logged within the 14-day construction period without any lost time, recordable incidents, or virus diagnosis.
How do you think health care design will change in the future as a result of the pandemic?
This pandemic has challenged us to rethink design and operation best practices for health care facilities. First and foremost, we must protect the health and safety of patients and staff. The standard patient room design currently does not require room pressurization. During this pandemic, we have created negative-pressure patient rooms to help mitigate contamination of other patients and staff.
Moving forward, we plan to incorporate design strategies for increasing the level of ventilation air on patient room floors to the extent of 100 percent outdoor air when necessary and maintain patient rooms under negative pressure.
We also found that many virus-infected patients become dependent on ventilators and dialysis equipment. Most standard patient rooms do not have the infrastructure in place for these systems. During the past five or six months, we have retrofitted patient rooms in numerous hospitals to include piped medical air and a dedicated power circuit to accommodate a portable ventilator and added water, drain, and power connections for portable dialysis equipment within some rooms.
With the increased use of ventilators, hospitals find that their bulk oxygen storage and distribution systems become overly burdened. They can overcome the liquid oxygen storage deficit with more frequent deliveries from their suppliers; however, the output of the system is limited by the capacity of the existing oxygen vaporizers and the carrying capacity of the building distribution system. We learned that the conventional sizing standards for oxygen and medical piping distribution systems need to be modified to accommodate the higher demands we have seen during this pandemic.
We have all seen the news about patients being treated in corridors and other non-clinical spaces out of necessity. We are now incorporating surge capacity—the ability to accommodate an increased patient population during an emergency condition such as a pandemic—into the design and retrofit of hospitals. Outfitting single-bed patient rooms with additional power and medical gases makes it possible to accommodate a second patient on a temporary basis. This has a significant impact on equipment infrastructure as additional capacity must be added to support the increased loads.
I believe that some of these practices and others will be adopted as new standards in the practice of health care design. Hopefully, we will never see another pandemic, but if we do, hospitals will be better equipped to accommodate the uncertain challenges.
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