From SARS CoV-1 2003 to SARS CoV-2 2019: Healthcare Leadership Strategies for a Better Future

From SARS CoV-1 2003 to SARS CoV-2 2019 Healthcare Leadership Strategy for a Better Future A guide to help reduce the transmission of highly contagious diseases within a building

JPT Architects and Engineers 814-536-5321 www.JPTarchs.com

MESSAGE FROM JPT ON COVID-19

JPT believes that we are truly in this together. We thank everyone for the sacrifices you have made and continue to make. Over the course of the summer and into the fall, we are going to continue forward with patience and understanding during this difficult and challenging time.

Wearing face masks when out in public and practicing social distancing is something that we are all practicing and encouraging others to practice as well. As our focus is dedicated 100% to the healthcare industry, we want to help our healthcare and medical clients as much as possible by staying safe and taking precautions to protect ourselves, our families and communities.

TABLE OF CONTENTS

Introduction - SARS and COVID-19 Facility Planning Strategy Should Include: “The Bug” Built Environment Building Infrastructure Healthcare Facility Specifics Practice Safe Control with Airborne Particles

HVAC System Utilization HVAC System Examinations Plumbing System Examinations Electrical Systems Examinations Technology System Examinations Operating During Shutdowns Remote Building System Monitoring

INTRODUCTION

During the SARS outbreak in 2003, we thought that we would be much better prepared for the next respiratory disease outbreak with contagious airborne particles. As we saw when the COVID – 19 pandemic came to China at the end of 2019 and the rest of the world in 2020, all of our healthcare systems around the world could have been better prepared. Using this guide will help healthcare facility leaders to use knowledge from the past and present to prepare for the future with COVID – 19. In simplest terms the most important things that you can do for your healthcare facility include:

• Be prepared • Plan for the worst • Have supplies on hand • Train your staff • And most of all...Expect the unexpected

In 2003 when the SARS virus was devastating the world with an earlier pandemic about 17 years ago, Canada was one the countries most severely effected by the virus. Canadian healthcare leaders used the knowledge that they gained during the 2003 SARS pandemic to put strategies in place for the fight against similar highly contagious respiratory illnesses.

This guide takes a look at a lot of those specific strategies that were learned in Canada during the 2003 SARS virus in addition to knowledge from the Architects and Engineers at JPT Architects.

FACILITY PLANNING STRATEGY SHOULD INCLUDE:

The Bug • Consider the bug, be it viral or bacterial? » Find out how it lives, what is necessary for “life”? » Where it lives, reproduces, transmission mechanisms/agents, how big is it, and how it dies • Armed with this information, a facility will be better able to choose its weapons of war

Built Environment • Ensure adequate supply of Personal Protective Equipment (PPE) • Routine area disinfection • A risk co-worker planning • Department Colleague movement and spacing

• Control access through few access points with ready staff identification • Modified normal testing protocols for staff, patients, and visitors • Building lockdown, restriction requirements, and staff communication » All individuals entering building must wear face mask » All staff screened upon entry depending on recommended procedures » Possibilities include temperature, symptom observations, screening questions, etc.

• Visitor restrictions in place, limited entrances & exits » Common example: No visitors allowed unless visiting someone critically ill or are parents of children

• Create an Emergency Coordination Committee » Intimate knowledge of building infrastructure included » Multi-discipline » Record daily successes and challenges » Record daily building system operating changes

» Record daily census, infected & not infected; patients & staff » Daily status update broadcast throughout the facility • Track all workorders in the contaminated areas » Schedule maintenance work when rooms are empty- not in use by patients or visitors » Educate all department leaders and staff on the technical aspects of the building environment

Building Infrastructure • Mechanical/Electrical redundancy/duplicity • Suitability for new operations; system analysis, maintenance and testing • Daily documentation and record keeping of infrastructure operations • “Pro-Active” retrofits where appropriate • Leverage existing system capabilities and technologies • Verification of negative pressure in segregated areas • Create airborne isolation areas as appropriate (negative air units)

• All exhaust HEPA filtered.

• Log & retain all consultant and vendor reports • Provide flexible ventilation systems with easy adjustability • Ensure exhausts and air intakes have adequate separation

Healthcare Facility Specifics • Assess healthcare system campus to development cohesive plan of action to utilize resource availability • Create “Pandemic Units” by grouping hospital personnel into teams to provide practical approaches to protect other healthcare personnel (HCP), patients and communities » Some call them “pandemic units” » Units should be under negative pressure * Keeping door shut in negative pressure rooms is critical » Limit access and egress » Create transfer areas for equipment and supplies to minimize unit traffic and person/person contact • Map out travel paths for infected patients starting from building entry to desired treatment destination » Include elevators and stairwells in the plan to separate traffic streams

• Map out travel paths for the general building layout of hospital patients, staff and visitors that are not infected (elevators and stairwells) » “Infected” paths should not cross “clean” paths • Select low risk “common areas” • Emphasize awareness to continue social distancing, wearing masks, staying home if you’ve been exposed, ventilation • Identify high risk areas within the hospital and specialty care spaces » Examples include operating rooms, cancer care, maternity care, and much more

• Good record keeping of patient information for those that have been infected by COVID – 19 » Includes patient medical records and patient contact history • Follow infection control protocols diligently • Provide surge capacity to address infection outbreaks • Ensure patient spaces are sufficiently large » Maximize separation distance between patient/patient, patient/staff and staff/ staff Practice Safe Control with Airborne Particles • Filtration - Particles in the air move through a filter which essentially removes the particles from the air stream • Dilution - The more outdoor (fresh) air that is being blown through the building, the cleaner the air inside will be • Gooseneck Faucets - This faucet type has a plain end and a laminar flow controller which minimizes splashing » Remove aerators or replace fixtures • A person “recovered” from COVID-19 still has the ability to generate SARS - CoC-2 aerosols via toilet flushing for weeks after testing negative via a respiratory tract test » Install toilet lids » Provide training materials on importance of flushing only when lid is down • Ultraviolet Light & Air Particle Ionization - Bacteria and mold spores are killed off with the use of ultraviolet light or ionizing air particles » Consider using portable units in patient treatment and sleeping areas

• Restroom Exhaust - To remove aerosol type containments, increase restroom exhaust levels HVAC System Utilization • Ventilation Procedures - central systems » Ensure that all preventive and corrective maintenance has been performed » Increase the use of outdoor air * Fresh/diluted air carries fewer germs » Spring & Fall - no issues with heating/cooling capacity » Winter & Summer - may run into fresh air limits due to heating/cooling coil capacity while maintaining temperature and relative humidity » Consider changing filter efficiency (increase) to eliminate airborne contaminates » Consider outdoor air quality (pollution) before increasing outside air quantity » Modify or override building automation system controls to maximize air flow through the facility » Hospitals and Outpatient facilities can utilize these procedures

• Portable/temporary filtration » In-room air filtration units can be used » High maintenance required * Minimum after every patient » Can be combined with onboard UVGI systems » UVGI lights can be installed inside central system ductwork at the point of use HVAC System Examination • Create strategic master planning for flexible, innovative, integrated building systems • In all probability, the building systems are not operating as originally designed » Programmed to satisfy current (or pressing) need • Identify the “new normal” set of operating standards for the HVAC systems • Analyze the current needs (occupancies, etc.) and calculate the required Standard Operating Procedures (SOP) • Commission/balance the systems to satisfy the current need • During commissioning, determine the maximum system capacities • Calculate the difference the new SOP and the maximum system capacities

» Difference becomes the system “surge capacity”, or the amount of reserve capacity that can be used to support new equipment, services, new construction, or simply the amount of horsepower available to maximize the outdoor air use • Determine the bottlenecks within systems that preclude other parts of the system from reaching their maximum potential » First targets for modernization or replacement • Prepare your building systems against airborne transmission of diseases and other indoor contaminants both physically (filters, maintenance, UVGI) and operationally (BAS programming & control).

Plumbing System Examinations • Create strategic master planning for flexible, innovative, integrated building systems • Restrooms need special attention because of the human body’s ability to harbor SARSCoV-2 • Review the water management plan for your healthcare system or buildings • Flush stagnant water out of building system when unoccupied for more than a week.

• Remove air blower type hand dryers • Increase restroom exhaust » Design levels are not based on removing aerosol particles and focus on acceptable odor levels instead • Increase cleaning frequency

• Higher amounts of exhaust over supply air to facilitate negative pressure to adjoining space • All plumbing fixtures should be installed or changed to automatic/touchless devices so no surfaces are ever touched and/or contaminated • Toilet lid installation » Training information distributed on importance of flushing only when lid is down * Usually on back of door so message is directly in front of individual sitting on the toilet » Install toilet lids wherever possible Electrical and Telecommunications (Tele-Data) Systems • Create strategic master planning for flexible, innovative, integrated building systems • Evaluate network hardware, software, electrical systems, data center cooling systems, and resiliency of telecommunication service providers • Cancel all except essential meetings » Communicate with staff via virtual meeting, electronic message boards, email and so many other forms of communication that are not face to face • Establish universal remote access to Hospital or Healthcare System Tele-Data software and servers for all staff » Maximize the use of remote workstations for staff to work from home • Deploy and utilize voice activated communication devices. Establish a cleaning routine for all shared devices • Minimize the need to come in direct contact with another person » Use telemedicine mobile and desktop apps for patient appointments » Encourage the use of apps for patient registration » Communicate with inpatients via nurse call and tele-data systems for meal service, routine bed checks, etc

» Use cameras for routine monitoring of patients * Enter patient rooms only when necessary » Disable any kiosk use » Implement hand-free auto-doors everywhere possible • Provide patients, especially those with ongoing treatments, or recovering at home, a means to communicate with their healthcare provider via the Internet

» Clear and precise instruction are essential to make this work Future Technology System Potential • Create strategic master planning for flexible, innovative, integrated building systems • Cameras can be utilized throughout the space for everyday task performance such as remote equipment monitoring • Place more visual and graphical displays throughout building for wayfinding, messaging and patient status • Utilize sensors; proximity, infrared, motion,…….. for every day tasks » Touchless entry doors and other high traffic interior doors » To avoid unnecessary touching of surfaces, use phone apps, voice, sensors, etc. » Vacancy sensors changed to occupancy sensors so no useless contact

• Additional anti-bacterial receptacles strategically placed around the building • To alert staff of guests with high temperatures, utilize commercial human thermal scanning equipment at entry areas and other strategic locations • Power systems and telecommunication systems should be established with builtin, automatic switching redundancies.

• Telecommunications consistency plan • Telehealth and telemedicine options • Infected patients will need remote communication if recovering from home • Asset management (tracking) and contact tracing helps regulate spread of viruses » Identifying where equipment was last and who has been in contact with it helps reduce time needed for contact collection data * RFID or GPS tracking devices add to equipment * Software for electronic sign in/out

• Concepts that help adapt electrical and technological systems along with other efforts to minimize virus transmission » Clear and simple process for staff to access workstations remotely if possible » Consider and plan for resilient Wi-Fi and connectivity » Eliminate single points of failure in power and mechanical system by developing infrastructure analysis • As precursor to building artificial intelligence (AI) applications, aggregate sensors for big data capture and analytics

OPERATING DURING SHUTDOWNS

Remote Building System Monitoring Tips • Although hospitals and a large portion of other healthcare facilities don’t shut down like other occupancies are doing during COVID-19, it is still important to understand how to monitor facilities that are completely and partially shut down » Many hospital system administration staff along with some Facility Directors, Maintenance personnel and IT professionals are working remotely at home • Proven strategies to lower energy use, produce consistent monitoring of building systems along with maintaining healthy and resilient facilities » Consider following before setting facility or designated are to “unoccupied mode” * Alarms – high/low room or zone temperate setup? * Unoccupied high humidity alarm? * Allowed to maintain an unoccupied humidity set point in systems? » Take a look at expected use of equipment by looking at the schedule for the facility * System level or terminal zone level » Some equipment may not fully shut off so either relax set-points or use stand-by mode of able to » Observe humidity at interior level or at air handling unit sensor can increase humidity levels * Damage to building and human health concerns can both result from incorrect humidity monitoring and control » If facility is opening fully or in-part after the shut-down, set everything back to normal

JPT ARCHITECTS, P.C. Architects - Engineers - Planners - Consultants Over the last two decades, JPT Architects has done a brilliant job developing our brand and enhancing our depth of knowledge in the field of healthcare Architecture and Engineering. We are dedicated to crafting distinctive and responsive spaces that go above and beyond the standard design experience.

Contact Info Johnstown Office (Headquarters) - 244 Walnut Street, Johnstown, PA 15901 - 814.536.5321 Hollidaysburg Office - 215 Allegheny Street, Suite 101, Hollidaysburg, PA 16648 - 814.695.1406 State College Office - 204 East Calder Way, Suite 305, State College, PA 16801 - 814.234.9470 www.JPTarchs.com

Improving the delivery of patient care is at the heart of everything we do. And like the healthcare systems we serve, JPT takes a holistic approach to this mission.

Healthcare Projects: 1,140+ Outpatient Centers: 110+ Diagnostic Imaging: 70+

In-Hospital: 750+

100% firm-wide focus in the healthcare industry - the only type of projects we do!

Oncology: 80+

Services range from campus master planning to pre-design, flow analysis, cost estimating, MEP integration, Construction management and more.

We are able to achieve an industry low 1% rate on change orders through our collaborative approach and use of virtual design and engineering technology on every applicable project. This coupled with our expertise in healthcare code compliance and instant access to experts from planning through construction, means that we deliver a project on time, on budget and above expectations.

HOLLIDAYSBURG OFFICE: 422 ALLEGHENY STREET – SUITE 202 – HOLLIDAYSBURG, PA 16648 – PHONE: 814.695.1406 JOHNSTOWN OFFICE: 244 WALNUT STREET - JOHNSTOWN, PA 15901 - PHONE: 814.536.5321; FAX: 814.535.2119 STATE COLLEGE OFFICE: 3500 EAST COLLEGE AVENUE - SUITE #1100 - STATE COLLEGE, PA 16801 – PHONE: 814.234.9470

www.JPTarchs.com