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HealthcareFacilities JOURNAL OF CANADIAN HEALTHCARE ENGINEERING SOCIETY

Volume 40 Issue 3

Summer/Été 2020

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CONTENTS

CANADIAN HEALTHCARE FACILITIES Volume 40

Issue 3

EDITOR/RÉDACTRICE

Clare Tattersall claret@mediaedge.ca

PUBLISHER/ÉDITEUR

Kelly Nicholls kellyn@mediaedge.ca

PRESIDENT/PRÉSIDENT

Kevin Brown kevinb@mediaedge.ca

SENIOR DESIGNER/ CONCEPTEUR GRAPHIQUE SENIOR

Annette Carlucci annettec@mediaedge.ca

PRODUCTION MANAGER/ Rachel Selbie DIRECTEUR DE rachels@mediaedge.ca PRODUCTION CIRCULATION MANAGER/ Anthony Campbell DIRECTEUR DE LA circulation@mediaedge.ca DIFFUSION

DEPARTMENTS

CANADIAN HEALTHCARE FACILITIES IS PUBLISHED BY UNDER THE PATRONAGE OF THE CANADIAN HEALTHCARE ENGINEERING SOCIETY.

Editor’s Note

SCISS JOURNAL TRIMESTRIEL PUBLIE PAR SOUS LE PATRONAGE DE LA SOCIETE CANADIENNE D'INGENIERIE DES SERVICES DE SANTE.

President’s Message

Chapter Reports

CHES Canadian Healthcare Engineering Society

SCISS

Société canadienne d'ingénierie des services de santé

PRESIDENT VICE-PRESIDENT PAST PRESIDENT

INFECTION PREVENTION & CONTROL

TREASURER SECRETARY

Preparing for a Pandemic Se preparer à une pandémie

24 Getting Ahead of the Curve Rural Ontario hospital puts four-pillar plan in place to keep patients, staff and physicians safe

30 Back to Nurture Building an IPAC culture improves care, outcomes 32 Anatomy of an Isolation Room Design criteria, requirements to ensure AIRs control spread of infectious diseases

26 Herding Cats What it’s like to work in facilities management during a pandemic

EXECUTIVE DIRECTOR

Roger Holliss Craig Doerksen Preston Kostura Kate Butler Reynold Peters Donna Dennison

CHAPTER CHAIRS

Newfoundland & Labrador: Colin Marsh Maritime: Helen Comeau Ontario: Jim McArthur Quebec: Mohamed Merheb Manitoba: Reynold J. Peters Saskatchewan: Greg Woitas Alberta: Dan Ballantine British Columbia: Norbert Fischer FOUNDING MEMBERS

H. Callan, G.S. Corbeil, J. Cyr, S.T. Morawski

28 A Disaster Like No Other Lessons learned in healthcare help ready response

CHES

29 Crisis Connections Social distancing doesn’t mean social isolation in digital age

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EDITOR'S NOTE

GIVING THANKS 2020 IS ONE YEAR you won’t forget, though most would rather put it behind them. Other than a family coronavirus scare in early April (which turned out to be nothing more than just that as the test came back negative), I’ve been very lucky. Sure, I’ve experienced my share of economic hardship due to COVID-19, but this is nothing compared to losing a loved one to the infectious disease. And although holding a job while homeschooling and running essential errands for my elderly parents has been a juggling act, it comes nowhere close to what healthcare workers have had to endure. This includes those who work behind-the-scenes but are still very much part of the frontline. It therefore only made sense to explore what it has been like to be in healthcare during the pandemic. Three members — Dave Millan, Mitch Weimer and Craig Doerksen — graciously took me up on my storytelling offer and provided personal accounts from a professional perspective. Not surprisingly, this issue is dedicated to infection prevention and control and, more specifically, the global health crisis that forced Canada to lockdown in mid-March and has dominated much of our thoughts and behaviour ever since. While some articles might strike a chord for their similarity to happenings at your healthcare facility, others will be unique and hopefully offer a learning opportunity. I’d like to thank everyone who carved out time to contribute content, especially given how busy you’ve been over the past few months. Your commitment is nothing but inspirational.

Clare Tattersall claret@mediaedge.ca

Reproduction or adoption of articles appearing in Canadian Healthcare Facilities is authorized subject to acknowledgement of the source. Opinions expressed in articles are those of the authors and are not necessarily those of the Canadian Healthcare Engineering Society. For information or permission to quote, reprint or translate articles contained in this publication, please write or contact the editor. Canadian Healthcare Facilities Magazine Rate Extra Copies (members only) 25 per issue Canadian Healthcare Facilities (non members) 30 per issue Canadian Healthcare Facilities (non members) 80 for 4 issues A subscription to Canadian Healthcare Facilities is included in yearly CHES membership fees.

6 CANADIAN HEALTHCARE FACILITIES

La reproduction ou l’adaptation d’articles parus dans le Journal trimestriel de la Société canadienne d’ingénierie des services de santé est autorisée à la condition que la source soit indiquée. Les opinions exprimées dans les articles sont celles des auteurs, qui ne sont pas nécessairement celles de la Société canadienne d’ingénierie des services de santé. Pour information ou permission de citer, réimprimer ou traduire des articles contenus dans la présente publication, veuillez vous adresser à la rédactrice. Prix d’achat du Journal trimestriel Exemplaires additionnels (membres seulement) 25 par numéro Journal trimestriel (non-membres) 30 par numéro Journal trimestriel (non-membres) 80 pour quatre numéros L’abonnement au Journal trimestriel est inclus dans la cotisation annuelle de la SCISS.

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Costa advised that he no longer wished to occupy his role as president. The emergency meeting took place at the defendant’s (MTCC 1292’s) premises. At the emergency meeting, the plaintiff and Mr. Da Costa entered into a heated argument, which led Mr. Da Costa to “lose it” and strike the plaintiff on the head with a chair. Mr. Da Costa was charged by the police and received a conditional discharge for assault with a weapon. iff commen The plaintiff commenced a civil action against Mr. Da Costa fo for his use of force as well as MTCC TCC 1292 for fo failing to ensure her safety and nd failing to employ security meet measures at board meetings. MTCC 1292 brought a motion summary judgment otion for su to dismiss the plaintiff’s plaintiff’ claim against it nly opposed by Mr. Da Costa which was only given his crossclaim MTCC 1292 ossclaim against ag on and indemnity. inde for contribution

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Jason Scott, Division Manager, FMO, Black & McDonald, is well aware of the complexities of undergoing healthcare retrofits. With five years to reflect on since the Women’s College Hospital project launched, success, he says, has a lot to do with preparedness: “Our proactive, hands-on approach to operations began long before the new facilities were commissioned. This early start enabled us to ensure a smooth transition for the clinical, maintenance and security staff moving to the new facility.” That’s not to say there weren’t any challenges. From demolition dust and debris, to heavy vibrations felt during construction, numerous disturbances were at play. Early tactics to mitigate these factors involved engaging all stakeholders, hospital departments and

clinical units about their functions, roles and responsibilities long before the transition began. “Staff members were also provided the opportunity to acclimatize themselves with the new facility’s layout during the detailed phase planning meetings,” he says, adding that re-training existing maintenance and security staff was another top priority. “We spent ample time empowering them with the latest best practices to ensure they’d be successful from day one at the new facility. This was a significant endeavour considering the amount of services that needed to be consolidated and transitioned.” SYSTEMS, SERVICES & THE PURSUIT OF SUSTAINABLE EXCELLENCE As the hospital’s medical, maintenance and security staff underwent the transition, Black & McDonald’s mechanical and electrical teams had their own set of goals: To provide complete HVAC, plumbing, specialized medical systems, electrical equipment and various ongoing services to the new facility. Informed by a comprehensive systems assessment and energy audit conducted in Phase 1, the team was able to identify key areas for improvement and subsequently work toward achieving efficiencies at the systems level. Known for its commitment to excellence in service and customer care, Black & McDonald also strives to meet the highest standards of sustainability. With features ranging from green roof coverage and heat recovery system, to energy-efficient window glazing, the new Women’s College Hospital was designed to offer numerous community and green benefits. However, the pursuit of sustainable excellence didn’t end there. “We continuously fine-tune various aspects of the hospital’s electrical and

WORKING IN MISSION-CRITICAL ENVIRONMENTS

Black & McDonald understands the challenges of working within mission-critical environments of healthcare facilities undergoing extensive construction, renovation and maintenance work. As such, the team strives to minimize and whenever possible eliminate disruptions within the facility during shut-downs or tie-ins of new to existing systems. As was the case at Women’s College Hospital, a seamless transition with minimal disturbance to staff, patients and visitors is always the goal. Of equal importance, personnel are trained for Infection Control procedures when working in operational areas to reduce risk to healthcare staff, patients, and visitors.

mechanical components as occupancy fluctuates throughout the clinical, diagnostic, office and retail spaces during the day,” says Abiola Adebayo, Energy & Sustainability Project Manager. “Our number one priority is to ensure we are putting our best foot forward in terms of energy conservation and sustainable operations.” To that end, Black & McDonald has created a robust energy management plan, which breaks down and prioritizes implementation of energy conservation measures in phases, factoring in the significance of impact, cost of implementation, and the critical nature of the space in consideration. “Additionally, we benchmark our energy performance on a regular basis with other comparable healthcare institutions in terms of Energy Usage Intensity (EUI), while adjusting for other parameters unique to each healthcare facility,” Abiola explains. “This helps us quantify how much room for further improvements we have. We are deeply committed to reducing our overarching carbon footprint and achieving our targets, and the success we’ve had thus far wouldn’t be possible without the efforts and commitment of our Operations teams and input from our stakeholders at the hospital.” With 2020 marking the fifth year since the hospital’s reopening, it’s safe to say the redevelopment project is considered a success by all. From the specialized hospital systems installed and managed by the mechanical team, to the seamless transition of employees at start-up, the ambitious goals set by Black & McDonald will continue to guide the way forward, and contribute to the ongoing legacy of this remarkable facility. Visit www.blackandmcdonald.com for more information.

CHAPTER REPORTS

QUEBEC CHAPTER

ALBERTA CHAPTER

Summer brought a different type of wave this year: COVID-19. Its spread has taken many countries by surprise and placed enormous stress on healthcare systems. Modifications have been made at a rapid pace to accommodate a new type of patient and protect the workforce, with innovative solutions coming from facility managers. Many individuals had to rely on internal resources and their own knowledge. The Quebec chapter held its first event of 2020 in February, at McGill University Health Centre’s Glen site. It included a tour of the mechanical rooms followed by a conference on legionella in the hospital water network. The event was a huge success with more than 70 people in attendance, including Ontario chapter chair Jim McArthur whose presence was valued. We’d like to increase interactions with other chapters on a national level, as well as bring local healthcare facility communities together. As the industry moves to new building layouts and solutions to cohabit with the presence of the coronavirus, the Quebec chapter will host a variety of informative webinars in the coming weeks. We will continue to monitor the situation closely across the province and adapt our offerings accordingly. Check the Quebec chapter page on the CHES website regularly and follow us on social media to stay up-to-date.

After the stress and uncertainty of the last several months, I am sure we all deserve some relaxation this summer. Remember, safety should still be the number one priority. I am fortunate to be the facilities maintenance and engineering manager at the Peter Lougheed Centre in Calgary. The Alberta government has announced the hospital will undertake capital upgrades. These projects are the only ones slated in the province for the near future. The plans include a new medical device reprocessing department suite, emergency room expansion, rapid response laboratory and mental health short stay expansion. We are going to be busy at my site. The chapter executive is looking to establish a bursary program at the Northern Alberta Institute of Technology, similar to what is provided at the Southern Alberta Institute of Technology. Supporting continuing education has been a very rewarding endeavour. CHES Alberta hosted its first virtual annual general meeting on June 15. I’d like to thank the events management team for helping coordinate the meeting to ensure it was a success. —Dan Ballantine, Alberta chapter chair

NEWFOUNDLAND & LABRADOR CHAPTER

L’été 2020 nous a apporté un nouveau type de vague: la COVID-19. Sa propagation a pris de nombreux pays par surprise et a imposé une pression énorme sur les systèmes de santé. On s’est rapidement adapté pour accueillir un nouveau type de patients et protéger la main-d’œuvre; les gestionnaires d’installations ont proposé des solutions innovantes à cet effet. La section québécoise a tenu sa première activité de 2020 en février, sur le site Glen du Centre universitaire de santé McGill. Elle consistait en une visite des salles mécaniques, suivie d’une conférence sur la legionella dans le réseau d’eau de l’hôpital. Ce fut un énorme succès : plus de 70 personnes y ont participé, dont le président de la section ontarienne, Jim McArthur. Sa présence a été appréciée. D’ailleurs, nous aimerions accroître nos interactions avec les autres sections et rassembler les communautés régionales des installations en soins de santé. Alors que le secteur adopte de nouvelles solutions et de nouveaux aménagements afin de pouvoir cohabiter avec le coronavirus, la section québécoise organisera divers webinaires au cours des prochaines semaines. Nous suivrons de près la situation dans toute la province afin d’adapter nos offres en conséquence. Pour rester à jour, consultez régulièrement la page de la section québécoise sur le site web de la SCISS et suivez-nous sur les réseaux sociaux.

The first half of 2020 has been challenging. After being pounded by a major winter snowstorm that forced a state of emergency, the pandemic hit. Transitioning facilities for an expected influx of COVID-19 patients, constructing drive-thru clinics in multiple locations, and dividing staff and implementing rotating shifts are just a few things that have kept healthcare staff busy. Throughout this pandemic, we have seen time and again the importance of our work. On behalf of the chapter, I would like to express my gratitude to, and appreciation for, our frontline facilities management staff and management team. The amount of work completed (in many instances with skeleton crews) has been remarkable. Where would we be without everyone pulling together for the common goal? I cannot thank you enough. As a province, like many others, we are currently in an economic low, primarily as a result of COVID-19. But even prior to the pandemic, our provincial financial picture was bleak. The number of residential and commercial new builds is at a minimum, oil and gas projects are on pause, offshore drilling is at a standstill and almost all industries have seen a decline. As we anxiously await a federal stimulus program, the province chugs along at status quo. All economic predictions indicate this will continue for the next few years. For this reason, it is challenging for people to find funding to partake in such voluntary groups as CHES. Nevertheless, the chapter is pushing recruitment of vendors/suppliers, consultants and other healthcare dependents to improve membership enrolment. The chapter is sitting in a solid financial position. We are looking at creative ways of spending a portion of our funding, which includes investing in the continual learning for members through sponsorships, conferences and/or educational reimbursements.

—Mohamed Merheb, président du chapitre du Québec

—Colin Marsh, Newfoundland & Labrador chapter chair

—Mohamed Merheb, Quebec chapter president

CHAPITRE DU QUEBEC

12 CANADIAN HEALTHCARE FACILITIES

CHAPTER REPORTS

MARITIME CHAPTER

BRITISH COLUMBIA CHAPTER

After much deliberation involving all key stakeholders, the CHES National executive, board of directors and conference planning committee, we made the very difficult and unprecedented decision to postpone the 2020 CHES National Conference in Halifax to a future date beyond this year. Despite maintaining hope that we would be able to host the event, both the current pandemic state of the nation and future indicators do not bode well for a conference of this scale in 2020. We unanimously agreed healthcare will continue to have significant COVID-19 related challenges well into fall and we need to focus all resources and energy to that end. As a result of this decision, there are numerous actions CHES National is undertaking with Halifax exhibitors, delegates and sponsors and the conference planning committee. Our goal is to minimize everyone’s inconvenience as part of formalizing this year’s cancellation, while hopefully concurrently starting to lay the foundation for our conference next year. CHES Maritime’s fall education day is in the planning stage as the new norm for 2020 may be webinars. Stay tuned for speaker topics. The chapter is pleased to offer the Per Paasche bursary again this year. The $1,000 grant is open to all immediate family members of Maritime CHES members who are in good standing. The eligible person must be in a recognized program at a post-secondary education institute, such as a trade/vocational school, college or university. Although any career path is acceptable, preference is given to programs that could lead to a future career in healthcare facilities management, maintenance, operations or support. Applications for this year's bursary closed June 30. CHES Maritime is able to balance the books while offering several financial incentives to its members in the way of student bursaries, contributions to Canadian Certified Healthcare Facility Manager (CCHFM) exam fees, webinars, the fall education day and other rebates.

For only the second time in the chapter’s history, our conference has been disrupted. The first was in 1989, due to labour unrest. This year it was cancelled because of COVID-19. In lieu of our in-person annual general meeting, an e-mail was sent to members in June with reports and the budget set with a proxy vote. The conference committee will begin planning for the 2021 conference in Penticton, B.C. I would like to welcome Fraser Health Authority project manager Doug Davis to the chapter executive. Doug will serve in the role of secretary. He joins treasurer Rick Molnar, vice-chair Sarah Thorn, past chair Steve McEwan and myself as chair. Continuing in their current roles are Arthur Buse (membership), Mark Swain (communications), Mitch Weimer (public relations) and Caroline Reid (education). I would like to thank Ken Van Aalst for his years of service as treasurer and secretary. His calmness and guidance will be missed on the executive. We look forward to having Ken continue as an active CHES B.C. member. As the province continues to recover from harm caused by COVID-19, I encourage everyone to take advantage of the webinars that continue to be offered at no cost to chapter members. Additional webinars have been added with discussions on experiences and new practices that have been implemented during the pandemic. This is a great opportunity to learn and ask questions from respected CHES members from across Canada, including B.C.’s Mitch Weimer and Steve McEwan.

—Helen Comeau, Maritime chapter chair

SASK ATCHEWAN CHAPTER It’s hard to believe we’re already halfway through 2020. It seems like yesterday we were making plans to host the 2019 CHES National Conference. Our annual general meeting was held on the last day of the event, with approximately 20 members in attendance. The Member of the Year award went to Steve Kemp who has been involved in electrical consulting engineering on many healthcare and technically challenging projects over the past 24 years. Steve has been a CHES member for 17 years. He serves on the Saskatchewan chapter’s board of directors and sits on CHES’s partnership and advocacy committee. This year’s chapter conference has been cancelled due to COVID-19. It was to be held at the Delta Hotel in Regina, Oct. 19-20.

—Norbert Fischer, British Columbia chapter chair

TORONTO, CANADA SEPTEMBER 17-21, 2022 27TH CONGRESS OF THE INTERNATIONAL FEDERATION OF HEALTHCARE ENGINEERING

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—Greg Woitas, Saskatchewan chapter chair SUMMER/ÉTÉ 2020 13

CHAPTER REPORTS

ONTARIO CHAPTER

MANITOBA CHAPTER

Normally at this time of year, I would be reporting on the success of our spring conference. Unfortunately, a deadly virus showed up in early March, which not only caused the cancellation of our event in Windsor, Ont., but all CHES conferences across the country. The pandemic has presented many challenges to our members and their respective facilities. While it has been (and still is) a trying time for healthcare, the greatest consequence of this health crisis has been the loss of life. My thoughts go out to all who have been affected by COVID-19. Looking to the future, Ron Durocher is already assembling the planning team for next year’s conference in Niagara Falls, Ont., May 16-18. While the cancellation of this year’s event resulted in loss of revenue, the chapter is in good financial shape thanks to the success of previous conferences. We plan to try again for Windsor in 2023. At this time, all in-person events are cancelled or postponed. Chapter executive meetings will be held by conference call until it is safe again to meet face-to-face. CHES Ontario’s annual general meeting was June 19. Since the chapter is incorporated, there are additional requirements for holding a virtual meeting. This was sorted out in our bylaws at the AGM. Moving forward, all meetings can be completely virtual, when necessary. Planning will continue for the 2020 International Federation of Healthcare Engineering (IFHE) Congress in Toronto. Our last scheduled meeting was cancelled due to COVID-19, as was our trip to Rome to attend this year’s IFHE Congress. The chapter continues to provide bursaries to nine Ontario colleges. Three family bursaries are to be awarded this year. I’d like to acknowledge the chapter executive for their work and participation on various committees, both nationally and regionally, and their continued dedication to CHES. Also, thank you to Steve Rees and Gordon Burrill for arranging and facilitating the CHES COVID-19 webinars. Hats off to all, including our frontline staff, for the hard work and long hours that have been required to keep our facilities as safe as possible during this pandemic.

The Manitoba chapter has experienced its share of challenges as we work through the new way of doing business more virtually amid the pandemic. We, like other CHES chapters, cancelled our 2020 conference and trade show. We look forward to meeting up again next year, albeit under much different circumstances than 2019. The 2021 Manitoba chapter spring conference is scheduled for May 3-4, at the Victoria Inn Hotel and Convention Centre in Winnipeg. The theme is, Construction and Renovations in Healthcare Facilities. The need to reschedule the 2020 CHES National Conference in Halifax due to COVID-19 means the Manitoba chapter will host the event in 2023, as opposed to next year. Planning will continue in the near future. Together with Red River College’s Building Efficiency Technology Access Centre, CHES Manitoba has submitted a request for funding of a study on COVID-19 Infection Prevention and Control: Assessment of Humidity and Temperature in LongTerm Care Homes for Seniors. More information to come once we receive results of our collative request. The chapter has introduced two new awards to recognize individuals who excel in their line of work. The 2020 Facilities Management Award of Excellence goes to Bill Algeo of Health Sciences Centre Winnipeg. The recipient of this year’s Project Management Award of Excellence is Gary Dandeneau, regional director of capital planning and facilities management at the Interlake-Eastern Regional Health Authority. Congratulations to both on being the first awards recipients. I encourage our members to nominate candidates for next year. Also new in 2020, the Manitoba chapter sponsored the Award for Power Engineering Technology at Red River College. The $1,000 bursary was presented to Eric Juskowa, a power engineering technology student who completed the first term of the program with a minimum 3.0 grade point average. Just a reminder, the Canadian Certified Healthcare Facility Manager (CCHFM) designation is offered through CHES. Certification demonstrates you have the necessary education and experience, confirmed by an outside body, to qualify as an elite professional in the healthcare facilities field. The Manitoba chapter will cover the cost of the CCHFM selfassessment exam for members attempting it for the first time. If successful in passing, the chapter will pay to take the certification exam. In support of continuing education, the chapter will pay for regular members to take part in this year’s CHES webinar series. Details are on the Manitoba chapter page of the CHES website, along with more information about our contribution to the CCHFM exams. 2020 was an election year for the chapter executive. Members include Brent Kolton (vice-chair), James Kim (treasurer), Troy Lycan (secretary), Barry Doran (membership), Craig Doerksen (member-at-large), Tom Still (past chair) and myself (chair).

—Jim McArthur, Ontario chapter chair

The need to reschedule the 2020 CHES National Conference due to COVID-19 means the Manitoba chapter will host the event in 2023, as opposed to next year. It will be held in the province's capital of Winnipeg.

14 CANADIAN HEALTHCARE FACILITIES

—Reynold J. Peters, Manitoba chapter chair

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STRUCTURAL CHANGES WE ARE ALREADY SEEING: 1. Flexible, adaptable hospital spaces 2. Higher ceilings for better air flow 3. Wider and/or single-direction corridors 4. More single-patient rooms vs. multi-patient wards

engineers enable that vision, bringing the plans to full, operational life. “The flexibility comes from setting the columns in a regular pattern so that the interior walls can move if need be,” she explains. “Stairwells and elevators go somewhere permanent, but the rooms and interior spaces can be played with. That way, if one day more patient beds are required, or fewer offices are needed, the conversion is easy.”

The other benefit, says Watson, is that when the next infectious disease pops up, the allowances to move things around are already in place. “Having the available space and the means to allow for programming changes is crucial,” she says. “By using a grid layout, that space can be temporary and reconverted to something else when there is no longer a need for it.” OTHER TRENDS Along with flexible, adaptable spaces, hospitals are

changing in other ways too. Modern healthcare facilities today offer more single-patient rooms and fewer multi-patient wards. Additionally, Watson says the ceilings are getting higher and ceiling spaces are getting larger. “New hospitals are being built with more ceiling space for air circulation,” she observes. “Moving air and natural light have known health and wellness benefits, and, higher ceilings are more aesthetically pleasing.” In terms of COVID-19’s direct impact on hospital layouts, Watson prophesies interior corridors and pathways will widen. “If we need to keep people moving in a single direction, spaces will widen” she says. “And of course, internally we’ll see more touchless technology in elevators and other systems.” One thing, however, that likely won’t change when it comes to future hospitals is the building materials used to construct them. “Steel and concrete are here to stay,” Watson says. “I can’t imagine even a pandemic will change that.”

To learn more about RJC’s services, please visit www.rjc.ca or contact Jennifer Watson directly at Jwatson@rjc.ca.

“The flexibility comes from setting the columns in a regular pattern so that the interior walls can move if need be.” – Jennifer Watson, Associate, RJC Engineers

rjc.ca

PREPARING FOR A PANDEMIC Se preparer à une pandémie By/Par Rebecca Burns

t was the second week of March when things started to change. Schools across the country shuttered their doors to students and employers sent staff home to work. As city streets became eerily quiet amid shelter-in-place orders, hospitals country-wide were abuzz with the hustle and bustle of staff preparing for an influx of COVID-19 patients. In Quebec, the facilities management team at McGill University Health Centre (MUHC) was readying to go into overdrive. MUHC is a bilingual academic health network spread over four hospitals. The centre — one of the largest and most modern in North America — provides tertiary and quaternary care to the immediate population of Montreal and Quebec as a whole, supporting seven clinical missions and offering more than 70 specialty health services. In the beginning, facilities management’s primary task was to convert patient rooms from neutral or positive pressure to negative pressure. The first requests were, predictably, to switch over the rooms on the intensive care units. At MUHC’s Glen site, things ramped up quickly — an entire wing was converted in less than a week. MUHC’s emergency measures coordination centre (CCMU), a decision-making body comprised of infection control and clinical and administrative leadership, was responsible for establishing facilities management’s priorities. Working with the Ministry of Health, they assessed the province’s ever-evolving needs and how best to share the workload across the network. Next, facilities management received requests to convert 18 CANADIAN HEALTHCARE FACILITIES

es choses ont commencé à changer dans la deuxième semaine de mars. Dans tout le pays, les écoles ont fermé leurs portes aux élèves et les employeurs ont envoyé leurs employés travailler à partir de la maison. Alors que les rues des villes devenaient étrangement silencieuses en raison des directives de confinement, les hôpitaux de tout le pays étaient bousculés par l’agitation du personnel qui se préparait à un afflux de patients infectés par la COVID-19. Au Québec, l’équipe de gestion des installations du Centre universitaire de santé McGill (CUSM) s’apprêtait à passer en vitesse supérieure. Le CUSM est un réseau universitaire de santé bilingue réparti dans quatre hôpitaux. Le centre, l’un des plus grands et des plus modernes en Amérique du Nord, fournit des soins tertiaires et quaternaires à la population de Montréal et de l’ensemble du Québec. Il soutient sept missions cliniques et offre plus de 70 services de santé spécialisés. Au début, la tâche principale de la gestion des installations a consisté à convertir les chambres des patients d’une pression neutre ou positive à la pression négative. Les premières demandes ont été, comme on pouvait s’y attendre, de transformer les chambres des unités de soins intensifs. Au site Glen du CUSM, les choses se sont accélérées : on a transformé une aile entière en moins d’une semaine. Le Centre de coordination des mesures d’urgence (CCMU) du CUSM, un organe décisionnel composé de responsables du contrôle des infections et de membres des directions clinique et administrative, a été chargé d’établir les priorités dans la gestion

INFECTION PREVENTION & CONTROL regular inpatient rooms to negative pressure. These were designated for COVID-19 patients who were sick enough to be hospitalized but not in need of a ventilator. Ultimately, MUHC needed many more of these than ICU rooms; however, that reality didn’t reveal itself until several weeks into COVID-19’s arrival in Montreal. Despite being a world-class facility, it was not simple to convert spaces at the Glen site. While some modifications were achievable by modulating exhaust and supply dampers, other solutions involved installing plastic barriers with zipper openings and portable high efficiency particular air (HEPA) filtration units. In all cases, room conversions required finetuning of dampers or fans, as well as manual measuring to ensure appropriate room conditions were met (like differential pressure and exhaust f low rate) since the necessary instrumentation was not already in place. During these unprecedented times, priority has been given to form over function. Because of the time sensitive nature of requests, sometimes, while achieving the desired environmental conditions, solutions have had a less than ideal effect on the users. In certain cases, clinicians still have to open zippers or roll-up plastic when they need to reach patients. In order to minimize these inconveniences, each modification is carefully planned in collaboration and coordination with facilities management and the affected clinical teams, including nurses and doctors on the affected floors. The older infrastructure of MUHC’s Montreal General Hospital (MGH), Lachine Hospital and Montreal Neurological Institute and Hospital required a different type of intervention. In most instances, to convert a room to negative pressure, the team had to remove a window to exhaust a portable HEPA filtration unit to the outside. Some windows had been in place, untouched, for several decades. Despite the extra labour, MGH’s facilities management team managed to convert 23 ICU rooms to negative pressure in a week and a half, taking a whole floor to 26 COVID-19-ready rooms from just three. As time marched on, one ICU floor per hospital was deemed insufficient to support the potential influx of COVID-19 patients. The CCMU directed facilities management to begin work on

des installations. En collaboration avec le ministère de la Santé, il a évalué les besoins en constante évolution de la province et la meilleure façon de répartir la charge de travail au sein du réseau. Ensuite, la direction des installations a reçu des demandes de transformation de chambres d’hospitalisation ordinaires en chambres à pression négative. Celles-ci étaient destinées aux patients COVID-19 qui étaient suffisamment malades pour être hospitalisés, mais qui n’avaient pas besoin d’un ventilateur. Au final, le CUSM a eu besoin de beaucoup plus de ce type de chambres que de chambres en soins intensifs, mais cette réalité ne s’est révélée que plusieurs semaines après l’arrivée de la COVID-19 à Montréal. Bien que le site Glen soit une installation de classe mondiale, la transformation de ses espaces n’a pas été facile. Si certaines modifications ont pu être apportées en modulant les volets d’évacuation et d’alimentation, on a aussi eu recours à d’autres solutions, comme l’installation de barrières en plastique avec des ouvertures à fermeture éclair et d’unités portatives de filtration d’air à haute efficacité (HEPA). Dans tous les cas, la transformation des chambres a nécessité un réglage précis des volets ou des aérateurs, ainsi que la prise manuelle de mesures pour s’assurer que chaque chambre remplissait les conditions appropriées (comme la pression différentielle et le débit d’expulsion), puisque l’instrumentation nécessaire n’était pas encore en place. En ces temps sans précédent, la priorité a été donnée à la forme plutôt qu’à la fonction. En raison du caractère urgent des demandes, il est arrivé que, tout en permettant d’atteindre les conditions environnementales souhaitées, les solutions n’aient pas eu un effet idéal sur les utilisateurs. Dans certains cas, les cliniciens doivent encore ouvrir une fermeture éclair ou rouler du plastique pour atteindre un patient. Afin de réduire ces inconvénients au minimum, chaque modification est soigneusement planifiée en collaboration et en coordination avec la gestion des installations et les équipes cliniques concernées, y compris les infirmières et les médecins des étages concernés. L’ancienne infrastructure de l’Hôpital général de Montréal (HGM) du CUSM, de l’Hôpital de Lachine et de l’Institut et hôpital neurologique de Montréal réclamait un autre type d’intervention. Dans la plupart des cas, pour transformer une

LEFT TO RIGHT: Seats spaced more than six feet apart to allow for physical distancing at Royal Victoria Hospital's COVID-19 test centre. Healthcare professionals properly wash hands at a designated station, which is critical in the fight against the highly contagious virus. SUMMER/ÉTÉ 2020 19

INFECTION PREVENTION & CONTROL t

converting other patient units to negative pressure isolation rooms. This caused cascades of patients to be relocated to other units. In every case, a feasibility study had to be done to ensure the new space could support all necessary care activities, including ventilation, medical gasses and electrical capacity. Before patients could be transferred to the new area, day-to-day equipment had to be installed, too, which included everything from call bells to macerators and even new curtains. Simultaneously, facilities management was responsible for a flurry of other tasks aimed at reducing the risk of transmission within the four hospitals. Teams were busy removing half of all tables and chairs, as well as any magazine and pamphlet displays from public areas; and installing hundreds of additional hand sanitizer stations, hands-free sinks and Plexiglas walls in entrances, reception areas and around food service cashier stations. They also helped set up signage to encourage physical distancing, including reminders about MUHC’s new elevator, stair and water fountain etiquette. In concert, permanent and temporary partitions or separating walls made of drywall, Plexiglas and even curtains were installed in various clinical areas, including dialysis and emergency department waiting rooms. Teams also installed windows in more than 50 patient room doors at MGH and the Glen site so medical staff could observe patients without entering the room in full personal protective equipment. On top of that, facilities management managed the installation of three COVID-19 screening tents and a resuscitation tent for non-COVID patients outside MGH’s trauma/ambulance bay. 20 CANADIAN HEALTHCARE FACILITIES

TOP TO BOTTOM: Desks with Plexiglas walls were set up in front entrances for safety reasons. Montreal General Hospital facilities staff share a message to help ‘flatten the curve.’

pièce en pression négative, l’équipe a dû enlever une fenêtre pour évacuer l’air d’une unité portative de filtration HEPA. Certaines de ces fenêtres étaient en place, intactes, depuis des dizaines d’années. Malgré le surcroît de travail, l’équipe de gestion des installations de l’HGM a réussi à transformer 23 chambres en soins intensifs en une semaine et demie, faisant passer un étage entier de trois à 26 chambres prêtes pour la COVID-19. Éventuellement, on a jugé qu’il ne suffisait pas d’avoir un étage d’unité des soins intensifs par hôpital pour accueillir l’afflux potentiel de patients COVID-19. Le CCMU a demandé à la direction des installations de commencer la transformation d’autres unités de patients en chambres d’isolement à pression négative. Cela a entraîné une cascade de déplacements de patients vers d’autres unités. Dans tous les cas, il a fallu réaliser une étude de faisabilité pour s’assurer que le nouvel espace pourrait accueillir toutes les activités de soins nécessaires, y compris la ventilation, les gaz médicaux et la capacité électrique. Avant que les patients puissent être transférés dans la nouvel le zone, i l a fa l lu ég a lement i n st a l ler des équipements de base, comme des sonnettes d’appel, des broyeurs et même des rideaux. Simultanément, la direction des installations était chargée d’une foule d’autres tâches visant à réduire le risque de transmission au sein des quatre hôpitaux. Les équipes ont dû retirer la moitié des tables et des chaises, ainsi que tous les présentoirs de magazines et de brochures des aires publiques, puis installer des centaines de postes de désinfection des mains, d’éviers sans contact et de murs en plexiglas dans les entrées, les aires de réception et autour des caisses des services de restauration. En outre, elles ont contribué à la mise en place d’une signalétique encourageant la distanciation, notamment en rappelant les nouvelles règles concernant les ascenseurs, les escaliers et les fontaines. On a installé dans diverses zones cliniques des cloisons permanentes et temporaires ou des murs de séparation en placoplâtre, en plexiglas et même en rideaux, notamment dans les salles de dialyse et d’attente des services d’urgence. Les équipes ont également installé des fenêtres dans plus de 50 portes de chambres de patients à l’HGM et au site Glen, pour permettre au personnel médical d’observer les patients sans devoir pénétrer dans la chambre avec un équipement de protection individuelle complet. De plus, la direction des installations a géré l’installation de trois tentes de dépistage de la COVID-19 et d’une tente de réanimation pour les patients non infectés par la COVID, le tout à l’extérieur de la zone trauma/ambulance de l’HGM. Dans une deuxième vague de demandes du CCMU, on a confié à la direction des installations la transformation en pression négative de diverses salles afin de répondre à tous les besoins potentiels des patients COVID-19 attendus. Parmi les espaces ainsi convertis (à l’aide d’un système d’aide à l’étanchéité en pression négative placé devant les portes des salles à pression

INFECTION PREVENTION & CONTROL In a second wave of requests from the CCMU, facilities management was asked to switch over various procedure rooms to negative pressure in order to attend to all potential needs of incoming COVID-19 patients. Operating rooms, dentistry suites and interventional imaging were among those converted by introducing a negative pressure seal assist system in front of the doors of the positive pressure procedure rooms. With the introduction of various procedure rooms, how to safely transport a COVID-19 patient through the hospital soon became a preoccupation. Following clinical directives established by the CCMU, MUHC identified specific elevators at each hospital for COVID-19 patient transport. In order to reduce the risk of contamination and minimize downtime for cleaning, facilities management installed portable HEPA filtration units inside each elevator. After several months of working long days, evenings and weekends, facilities management has helped MUHC attain a certain level of operation. However, things continue to evolve. As the province plans for a slow ramp up to more regular day-to-day volumes and operations, establishing clear hot and cold patient zones is becoming increasingly important. It remains to be seen what the future holds for COVID-19 and MUHC, but what is clear is many of these ‘temporary’ modifications will likely become permanent. Rebecca Burns is responsible for the environmental dossier within the technical services directorate at McGill University Health Centre (MUHC). This article was written in collaboration with Steven Yamamoto, associate director of technical services at MUHC, and Justin Ciampini and Mohamed Merheb, facility managers at MUHC’s Glen site and Montreal General Hospital, respectively.

positive), mentionnons des salles d’opération, de dentisterie et d’imagerie interventionnelle. Maintenant qu’on disposait de ces types de salles, il fallait cette fois concevoir un protocole de transport des patients COVID-19 à travers l’hôpital. En suivant les directives cliniques établies par le CCMU, le CUSM a identifié, dans chaque hôpital, certains ascenseurs pour le transport de ces patients. Afin de réduire le risque de contamination et les temps d’arrêt pour le nettoyage, la direction des installations a mis en place des unités portatives de filtration HEPA dans chaque ascenseur. Après plusieurs mois de longues journées (et soirées et fins de semaine) de travail, la direction des installations a permis au CUSM d’atteindre un certain niveau de fonctionnement. Or, les choses continuent d’évoluer. Le gouvernement provincial prévoyant un retour très graduel aux activités et aux volumes normaux, il devient de plus en plus important d’établir des zones chaudes et froides bien claires. Il reste à voir ce que l’avenir réserve à la COVID-19 et au CUSM, mais on sait d’ores et déjà que nombre de ces modifications ‘temporaires’ risquent de devenir permanentes. Rebecca Burns est responsable du dossier environnemental au sein de la direction des services techniques du Centre universitaire de santé McGill (CUSM). Cet article a été rédigé en collaboration avec Steven Yamamoto, directeur adjoint des services techniques du CUSM, et Justin Ciampini et Mohamed Merheb, gestionnaires des installations du site Glen et de l’Hôpital général de Montréal (respectivement) du CUSM.

SUMMER/ÉTÉ 2020 21

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What’s your outbreak protocol? Communicable diseases cause a significant burden on society1 and the widespread outbreak of COVID-19 has brought a harsh reality for both healthcare and non-healthcare facilities alike. This respiratory disease, caused by a coronavirus, SARS-CoV-2, is a reminder of the importance of infection prevention efforts and the need for continued vigilance. 2 In the current COVID-19 pandemic, there have been numerous incidents of infection outbreaks at different types of non-healthcare facilities, such as large warehouses, food plants, meat manufacturing plants, grocery stores, etc. 3 As public facilities and business open in a phased manner after the unprecedented lockdown and closure due to COVID-19, it is imperative that cleaning, disinfection and infection prevention and control measures are undertaken and adhered to in order to prevent additional outbreaks. 2

Educate. COVID-19 has also highlighted the importance of infection control and prevention education for facility managers, custodians and professional cleaners to ensure facilities/businesses are cleaned and disinfected properly to help prevent the spread of illness causing germs and protect human health.4,5 Everything from hand hygiene to wearing masks to personal protective equipment, to choosing the correct product for each cleaning job, to knowing the proper process to implement, and execute environmental disinfection, all play a vital role in helping prevent the spread of communicable infections.4

Be “healthcare clean”. “Healthcare clean”, an approach to cleaning that aims to reduce or eliminate microbial contamination of all hard surfaces and non-critical equipment within the healthcare environment, may also be applied to non-healthcare settings, such as schools, offices, retail, hospitality, warehouses, fitness facilities, grocery stores, shopping centres, etc.6 Similar to practices implemented during normal flu seasons, it is important to ensure routine cleaning is being done when trying to stop the spread of mass communicable infections such as COVID-19.7 Surveys show that nearly all employees (86%) agree that disinfecting hard surfaces is one of the best ways to prevent germ transmission, and employers should make available and provide hand sanitizers and disinfecting wipes at employee workstations. 8

Plan to prevent.

CloroxPro™ can help.

Toronto Public Health has issued a COVID-19 factsheet for non-healthcare workplaces that recommends frequent cleaning and disinfecting of common areas and high-touch surfaces such as door handles, counters, cabinet doors, elevator buttons, light switches, faucets, toilet handles, hand rails, touch screen surfaces and keypads. Common areas should have soap, hand sanitizer and disinfectant. 9 In addition, the Ontario Ministry of Labour, Training and Skills Development, has issued comprehensive guidelines for various sectors of industry to help protect workers, customers and the general public from COVID-19:4,10 • Adherence to infection prevention and control (IPAC) protocols; • Hand hygiene, including the use of alcohol-based hand rub and hand washing; • Assessment of the risk of infection transmission and the appropriate use of personal protective equipment, including correct selection, safe application, removal and disposal; • Disinfect all frequently touched surfaces daily including desks, cubbies, cafeteria tables, restroom stalls/stall doors, door handles, keyboards/mice, pencil sharpeners and sink fixtures; • Disinfect after routine cleaning is complete; • Remove any visible soil from the surface with a detergent-based cleaner before applying a disinfectant; • Disinfect surfaces from “clean” areas, such as classrooms, to “dirty” areas, such as restrooms, to minimize crosscontamination; • When disinfecting, ensure surfaces remain visibly wet for the contact time specified on the product label.

The rapidly evolving situation with COVID-19 has triggered Public Health Agency of Canada’s (PHAC) Emerging Pathogen Policy*. This policy permits manufacturers of disinfectants to make efficacy claims for its disinfectants against the emerging viral pathogen if: • The disinfectant has a Broad Spectrum Virucidal efficacy claim, meaning that it has a claim against anyone of the following four viruses approved by Health Canada: Poliovirus type 1, Chat strain (ATCC VR-1562) or Human adenovirus type 5 (ATCC VR-5) or Bovine parvovirus (ATCC VR-767) or Canine parvovirus (ATCC VR-2017) • Or, carry a specific claim against a specific coronavirus, such as MERS-CoV, SARS-CoV or human coronavirus strain 229E • Or, carry a specific claim against non-enveloped viruses of the picornaviridae, caliciviridae, astroviridae, reoviridae, or papillomaviridae families The following CloroxPro™ products are on Health Canada’s list of hard-surface disinfectants with evidence against COVID-19: • Clorox Total T360® Disinfectant Cleaner, DIN 02460769 • Clorox® Germicidal Bleach, DIN 02459108 • Clorox® Disinfecting Wipes, DIN 02492636 • Clorox® Clean-Up® Disinfecting Bleach Cleaner, DIN 02494019 • Clorox Healthcare® Germicidal Disinfecting Cleaner, DIN 02469278 • Clorox Healthcare® Bleach Germicidal Wipes, DIN 02465671 • Clorox Healthcare® Fuzion™ Cleaner Disinfectant, DIN 02459744 • Clorox Healthcare® Hydrogen Peroxide Cleaner Disinfectant, DIN 02403528 • Clorox Healthcare® Hydrogen Peroxide Cleaner Disinfectant Wipes, DIN 02406225 • Clorox Healthcare® VersaSure™ Alcohol-Free Cleaner Disinfectant Wipes, DIN 02473151

* https://www.canada.ca/en/health-canada/services/drugs-health-products/disinfectants/covid-19/list.html References: 1. Diener A & Dugas J. Inequality-related economic burden of communicable diseases in Canada. Can Commun Dis Rep Suppl 2016;42:S1-S7. 2. Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. Best practices for prevention, surveillance and infection control management of novel respiratory infections in all health care settings. 1st revision. Toronto, ON: Queen’s Printer for Ontario; 2020. 3. These are the Calgary-area workplaces hit hardest by COVID-19 outbreaks. https://www.cbc.ca/news/canada/calgary/covid-list-workplace-outbreaksahs-calgary-asfd-1.5564639. Accessed May 11, 2020. 4. Resources to prevent COVID-19 in the workplace. May 8, 2020. https://www.ontario.ca/page/resources-prevent-covid-19-workplace. Accessed May 10, 2020. 5. COVID-19 Standard Operating Procedure – Disinfection of Touchpoints. https://www.ccohs.ca/images/products/pandemiccovid19/pdf/std-op-proc-disinfection.pdf. Accessed May 10, 2020. 6. Gauthier J. “Hospital clean” versus “construction clean” – is there a difference? Can J Infect Control 2004;19(3):150-2. 7. Cold and Flu Season. https://www.wsps.ca/Information-Resources/Topics/Cold-and-Flu-Season.aspx. Accessed May 10, 2020. 8. Clorox Professional Products Company Survey. May 2015. 9. Toronto Public Health Covid-19 Fact Sheet. https://www.toronto.ca/wp-content/uploads/2020/02/8d59-Fact-Sheet_NovelCoronavirus.pdf. Accessed May 10, 2020. 10. Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. Best practices for environmental cleaning for prevention and control of infections in all health care settings. 3rd ed. Toronto, ON: Queen’s Printer for Ontario; 2018.

Protection. Where it’s needed most. CloroxPro™ offers three chemistries for outbreak prevention that goes beyond just cleaning.

These Health Canada registered disinfectants, based on 3 chemistries, defend against COVID-19.* * The registered disinfectants are approved to communicate claims against emerging viral pathogens.

GETTING AHEAD OF THE CURVE Rural Ontario hospital puts four-pillar plan in place to keep patients, staff and physicians safe By Dave Millan

OVID-19 evolved from an epidemic to a pandemic in a few short weeks, increasing demands on the facilities team at Brockville General Hospital (BGH). Located between Ottawa and Kingston, Ont., BGH, as well as its partner agencies in the Thousand Islands region, faced many of the same challenges as larger hospitals

24 CANADIAN HEALTHCARE FACILITIES

and additional ones presented by a primarily older and rural population. The scientific community and various levels of government researched how the virus affects the population, which resulted in new protocols being developed and set forth. This has placed increased demands on the hospital’s facilities department. For instance, in-hospital care for COVID-19 patients is now required. To satisfy this need,

patient flow had to be adjusted to ensure negative pressure rooms are available to the clinical teams. Leading up to the state of emergency declared by the Ontario government in March, BGH’s senior leadership established an incident command structure. This allowed for formalized and standardized planning of operations and communication during the pandemic.

INFECTION PREVENTION & CONTROL

IT WAS KEY THE FACILITIES DEPARTMENT ENSURE STAFF AND PHYSICIANS WERE AWARE THAT APPROXIMATE TIMELINES TO COMPLETE WORK ORDERS WERE SUBJECT TO CHANGE, BASED ON NEED.

allowing for clear direction and response. The director of facilities and infrastructure was selected as the point of contact, mirroring BGH’s corporate communications strategy whereby all information is disseminated by the hospital’s marketing and communications department. COMMUNICATION PROTOCOLS

To mitigate challenges resulting from unclear operational communications, BGH fully implemented the incident management system within all protocols for emergency response. Internally, the facilities COVID-19 response plan has provided a start-of-shift toolbox briefing for the team. This system has mitigated any confusion staff may be exposed to while in the field. A SAFE WORK ENVIRONMENT

The subsequent response within the facilities department was rapid. The team reached out to their peers and consulted with the hospital’s in-house infection prevention and control (IPAC) department and health and safety groups to establish new and evolving standards for the organization. This provided a framework for facilities staff to prioritize their response to COVID-19. It includes four pillars to keep patients, staff and physicians safe during the pandemic: a central source of information; set of communication protocols; ensuring a safe working environment; and making adjustments based on clinical needs. CENTRALIZING INFORMATION

It was determined early on that information was flowing to the facilities department from multiple sources and some of it was contradictory or confusing to staff. The result was reduced productivity. To combat this, the team decided only one source would disseminate information,

As the team received multiple service requests, a new validated, systematic process was required in order to meet increased workload demands. A risk assessment process was implemented that clearly established hospital worker health and safety as a priority. A hierarchy of controls has been utilized as the standard to deter mine which activities and work orders are a priority based upon the following control measures: elimination; substitution, engineering controls; administration controls; and personal protective equipment (PPE). An example is the active COVID-19 screening program. Following the standard set out by the provincial government, the number of points of entry into the hospital was reduced. Screening was implemented, with designated staff donning and doffing PPE. Staff reported safety concerns with this process.

To create a better solution, facilities staff gathered information from internal stakeholders and determined a physical barrier would be beneficial at the screening desk, as well as support from a licensed security guard. Collaboration between the two groups continually enhanced the evolving screening process, with feedback resulting in the addition of a three-sided Plexiglas screen to the COVID-19 screening desk, a microphone for improved communication and an opening to allow for documents to be passed between screeners and clients. MAKING ADJUSTMENTS

It was key the facilities department ensure staff and physicians were aware that approximate timelines to complete work orders were subject to change, based on need. The surgical services program serves as an example. A large project was required to be completed in a short period for clinically vital work. In order to maintain surgical activity, the facilities team engaged several stakeholders (in-house resources from occupational health and safety and IPAC departments, and the hospital’s air balancing contractor) to create a negative pressure environment in the operating room. This would allow designated medical procedures to be completed, as per government issued protocols. Overall, the facilities department has been able to adjust and prioritize the demands of stakeholders during the pandemic. The keys to a successful response to this crisis is clear, consistent communication and engagement from the team. Dave Millan is director of facilities and infrastructure at Brockville General Hospital. SUMMER/ÉTÉ 2020 25

HERDING CATS What it’s like to work in facilities management during a pandemic By Mitch Weimer

ot long ago, someone asked what my job entailed. I thought it was a ‘funny’ question given I had worked with the person for 20 years. However, it got me thinking about what I actually do. Although my title is director of facilities maintenance and operations, I often feel like the chief cat herder. It has taken a while to figure this out and actually train the cats. (They really don’t take direction well.) Let me explain. In my role as a director of a regional health authority, I oversee many sites of different types and various vintages. Despite the distinctions between them, there is a desire by the organization to standardize mostly everything across the authority. However, what works for one acute care hospital may not for 26 CANADIAN HEALTHCARE FACILITIES

TRY DOING THESE THINGS AT 12 DIFFERENT ACUTE FACILITIES (AND STAT) ONLY TO BE TOLD TO DISMANTLE AN INITIATIVE BECAUSE IT DOESN'T WORK FOR ONE DEPARTMENT. another. When one long-term care administrator has an idea, it may not be applicable to the other 25 sites. Throw in complex care facilities and a diverse range of buildings, and it becomes like herding cats. So you might ask, how has COVID-19 affected your job, Mitch? Well, it just added a bunch of strange animals to the herd.

As we moved through the various stages of the pandemic, we had to address new items and issues while keeping up with old wants and needs. First on the list were isolation rooms. Then came oxygen supply concerns and the desire for negative pressure operating rooms (OR) — which, by the way, are against code — followed by requests to make a negative pressure emergency

INFECTION PREVENTION & CONTROL department trauma bay that doesn’t have doors and build OR anterooms in the OR corridor to fully engulf a stretcher but not impede workflow. (Say what?) Try doing Diesel Fuel System these things at 12 different acute facilities C o mpl iance & Upgrade s (and stat) only to be told to dismantle an initiative because it doesn’t work for one department. Then it was decided that we should try to build an antechamber (a small room to capture and exhaust air from a normal positive pressure OR). When asked to check the airflow and rebalance all the ORs, I asked, Which way should the air flow between an OR and sterile core? That didn’t go over well. It depends on when the OR was built, so every site has a different setup depending on its age. Afterward, someone remembered surgeries are performed not only in the ORs but in many other hospital departments. So, we had to test the airflow to confirm the relative pressures and air exchanges per hour in more than 300 procedure rooms across 12 acute care sites. When can you have that done, Mitch? Oh, by 1 Concorde Gate,Suite 808 the way, you have to work around our schedules Toronto, Ontario and we really don’t know when that room will 416.443.9499 be free. mcgregor- allsop.com Next was a construction worker walkout at one of our large construction sites. We were faced with the challenge of remedying the situation and getting people back to work at the (almost completed) facility, which was McGregor_Condo_March_2020.indd a major 2 cog in our COVID-19 surge capacity program. Canadian Healthcare Société canadienne d'ingénierie (The plan doesn’t work if the building isn’t ready Engineering Society des services de santé to take patients.) Throughout all this, we had physical distancing measures to consider. The cats were onboard but each wanted something different at their site (35-plus in total). In May, it was announced that B.C. had October 18 - 24, 2020 flattened the curve. This was great news as Recognize yourself, your department and your staff during we could start easing back to normal. But Healthcare Engineering Week. Make sure everybody knows the this also led to a plethora of requests: How vital role played by CHES members in maintaining a safe, secure fast can we convert an OR from positive to and functioning environment for your institution. negative pressure? (The authority needed to ramp up the surgical capacity to recover *2020 Challenge* from 14 weeks of cancelled surgeries). Can CHES Members are challenged to celebrate NHFEW by you make sure all ORs are ready to go and creating a short video and posting it on LinkedIn or Twitter using be open after hours? Oh, and remember the #NHFEW. CHES will then like and share it on LinkedIn 17 old medical device reprocessors that you (@CHES National Office) and Twitter (@CHES_SCISS). couldn’t get parts for? Well, we couldn’t get the funds for replacement but we need them all working overtime to support the increase in OR slates. (Sigh.) Visit the CHES Website www.ches.org/resources/ for downloadable material Mitch Weimer is director of facilities mainteto help you with plans to celebrate! nance and operations for the Fraser Health

Trust.

CHES

SCISS

2020-04-16 1:55 PM

National Healthcare Facilities and Engineering Week

Authority. SUMMER/ÉTÉ 2020 27

INFECTION PREVENTION & CONTROL

A DISASTER LIKE NO OTHER Lessons learned in healthcare help ready response By Craig Doerksen

aving spent my entire career in the healthcare sector, I have worked through many operational incidents and calamities — a scaffolding collapse, construction site fires, power outages, floods and loss of water, to name a few. Failure of major and minor equipment and systems has sometimes caught the facilities team off guard, but often system redundancy, the hospital’s skilled trades and service providers, spare parts and a MacGyver approach have continued delivery of safe patient care. In these instances, planning has been key to an effective response to disaster. We prepared for SARS cases (had none) and H1N1 outbreaks (had a few), and routinely practiced for other emerging diseases like Ebola and MERS. There are strategies in place to combat C. difficile, tuberculosis, measles, HIV, respiratory syncytial virus and yearly influenza strains. But all these experiences pale in comparison to the past few months. While COVID-19 first came to light in early January, it was work as usual until the first site hospital incident command meeting on March 2. Six distinct action steps were put in place at that time as part of HSC’s pandemic response: limit site access with the help of additional security, and screen the public and staff; prepare facilities for additional beds for intensive, acute and low acuity care; prepare and procure equipment and infrastructure to support bed surge; provide physical and ventilation control methods for aerosol generating medical procedures; implement enhanced cleaning and disinfection schedules; and engage regularly with staff to keep everyone abreast of personal health and safety measures given the highly dynamic changes occurring daily.

28 CANADIAN HEALTHCARE FACILITIES

I liken my days during the height of the pandemic in Manitoba to the movie, Groundhog Day. Everyday started and ended alike. I arrived at work early and was able to park in the same spot because of the massive reduction in traffic and on-site staff. From there, the 8 a.m. hospital incident command meeting drove the day. I’d leave for home around 7 p.m., and after dinner I’d spend the evening writing and responding to e-mails until about midnight. In-between the everyday monotony, we overcame obstacles and experienced significant professional growth as we applied new learnings and technology at a rapid pace. Existing solid relationships built with our clinical teams proved to be incredibly beneficial. They helped us work through their concerns; conversely, they knew the facilities department’s capabilities and building system limitations. We worked collaboratively to innovate and apply the right resources to solve problems. Corresponding and making decisions through the incident command structure ensured we were all on the same page. The way we communicated changed — Zoom meetings replaced conference calls, and we came to rely more heavily on verbal

communication and in-person interaction as time was of the essence. This is not to say e-mail disappeared; rather, it was only used to confirm decisions. The issues that arose during the pandemic were too large for any one group, so it was important to assemble wide scope teams. It became apparent the problem-solving abilities of housekeeping, security, maintenance, engineering and facility management personnel were essential to pandemic preparations. While HSC Winnipeg has made many changes, some temporary and others permanent, to address the risks during this health crisis, the pandemic is not a problem we solve or beat. It’s not like making it through a power outage, snowstorm or any other contingency. A note I saw on a social news platform should give us pause for thought: “Nothing should go back to normal. Normal wasn’t working. If we go back to the way things were, we will have lost the lesson. May we rise up and do better.” Craig Doerksen is divisional director of facility management at Shared Health, Health Sciences Centre Winnipeg.

INFECTION PREVENTION & CONTROL

CRISIS CONNECTIONS Social distancing doesn’t mean social isolation in digital age By Michael Oreskovich

alancing patients’ emotional needs with their safety has never been more challenging than during the COVID-19 crisis. Although social distancing is essential to prevent the spread of infection, it also has the potential to make patients feel alone and isolated at a vulnerable time. To offset this and ensure a quality patient experience, Runnymede Healthcare Centre adjusted its delivery of programs by leveraging digital technology. Beginning in February, the hospital put measures in place to protect patients and staff from the spread of COVID-19. These escalated dramatically when the pandemic was declared the following month. All visitation was immediately suspended and large group activities were put to a stop. The measures were essential but removed key sources of support for patients. “The limits on patients’ social interactions are necessary but they could also negatively impact their quality of life or even their therapy,” says Sarah K ing, Runnymede’s director of client relations and community engagement. “At a time like this, helping patients connect with loved ones and others in the hospital is crucial for preventing them from feeling disengaged or slipping into depression.” To maintain the patient experience while visiting restrictions are in effect, Runnymede has made tablet devices available, enabling face-to-face video chats with loved ones. In addition to helping patients stay connected, their use alleviates anxieties felt by families and loved ones who desperately want to provide support. “The devices are in non-stop use for video chats,” says King. “To meet the high demand, we’ve had to double the number of tablets we have at the hospital.” Since the devices are handled by multiple patients over the course of a day, they are cleaned between each use to

prevent the spread of infection. The tablets are also kept in protective enclosures that are designed to withstand regular cleaning with disinfectants. With safety modifications in place, the hospital continues to run its activation programs to the fullest extent possible. Sessions during the pandemic occur in smaller settings, with team members ensuring participants are kept a safe distance apart. Celebrations that normally would have been hospital-wide have been converted to f loor-based events involving smaller groups. In cer-

tain cases, tablet devices are incorporated into the hospital’s activation programming. “Some patients are enjoying virtual tours in place of regular outside trips, while others are taking advantage of streaming yoga classes,” says King. “For those who usually attend our religious gatherings, they can continue to have their spiritual needs met with online church services.” Michael Oreskovich is a communications specialist with Runnymede Healthcare Centre. SUMMER/ÉTÉ 2020 29

BACK TO NURTURE Building an IPAC culture improves care, outcomes By Craig Yee

t is well established in healthcare facility environments that infections related to construction, renovation or maintenance activities are a result of several breakdowns, such as lack of proper or clear policies and requirements, including sufficient control methods and measures; late or improper planning and design; late, improper, inadequate or no risk communications; and inadequate education, training and instruction. These represent symptoms of negative or fractured infection prevention and control (IPAC) cultures that exist and persist, even in today’s modern healthcare environments. If the objective is to protect occupants from infection risks, then these breakdowns cannot occur. Involved stakeholders must be on the same page to achieve IPAC success. A workplace culture is the character and personality of an organization, including shared attitudes, values, beliefs, perceptions, traditions, interactions and behaviours. With regard to IPAC, it is a healthcare facil-

30 CANADIAN HEALTHCARE FACILITIES

ity’s foundation upon which susceptible individuals are safeguarded from infections. Positive, collaborative and transparent healthcare facility cultures are critical to protect occupants from disease. At a high level, culture can significantly impact IPAC as demonstrated by many negative trends based on known evidence; indeed, infectious diseases resulting from various work tasks is not necessarily a result of random error or chance but caused by breakdowns in systems, processes, policies, communication and more. Positive cultures drive engagement and performance to achieve set goals and objectives. For stakeholders to really ‘buy into’ an IPAC culture, several elements need promoting. This includes senior leadership/ management commitments; implementing realistic, specific practices for addressing and mitigating infections; properly communicating across involved stakeholders (focusing on care and concern for occupant well-being); and committing to continuous organizational learning and improvement. An IPAC culture is not unlike worker

safety culture — infection control to population risk groups is essentially the same as safety to protect workers from hazards. The intents and principles are quite similar but the stakeholders and protection measures are slightly different. Like any workplace culture, it needs to be properly built and maintained for any modicum of success. If not, consequences can be quite significant, from unintended transmission of incurable diseases to occupant fatalities. Moreover, unaddressed risks can lead to other downstream problems, such as liability, culpability, reputational risks and even loss of public trust. One only needs to look at current infection events to understand the adverse outcomes when a broken, negative culture is allowed to persist. Committing to and focusing on a proactive, positive IPAC culture can prevent these consequences, over time. Organizations with positive commitments can better prioritize IPAC; anticipate risks, issues and problems; correct, rectify and control problems before harm is done; collaborate with various required stakeholders; and ‘own’

INFECTION PREVENTION & CONTROL accountability to protect occupants and improve safety outcomes. However, the road to achieving a positive IPAC culture is beset with several challenges that need to be considered (and cont rol led). T hese i nclude: lack of organizational, management and leadership commitment; uncertainty about who needs to be involved; prioritizing production or schedule over IPAC; miscommunications across the organizational hierarchy; ignoring ‘lessons learned;’ absence of proper education, training and instruction; competency failures; and fear of not adhering to political agendas and work schedules. Regardless of these roadblocks, the most significant question that needs to be asked is: What is each person doing to prevent infections? If the belief is that infections are preventable (just like safety accidents), then not doing anything or accepting the status quo is, in actuality, intending to have an infectious disease. For this reason, a paradigm shift is necessary. In fact, it can be argued that this shift is mandatory to protect occupants from potentially significant consequences of infectious disease. There is great opportunity for positive change. It is never too late to improve efforts to protect occupants from infection risks. However, tough questions need to be asked. Inquiries into why things are the way they are must occur. There is the opportunity to learn from past and current breakdowns, and make necessary improvements to start building a positive IPAC culture. Stewardship, ownership and leadership is required to challenge the status quo; accept past performance as not ‘good enough;’ rethink previous and current IPAC measures, practices and protocols; move toward more successful IPAC practices; and evolve from what was accepted to continuous improvement. To create a positive IPAC culture, several foundational building blocks need to be implemented, established and maintained, including leadership/management commitments; risk management systems; continuous improvement systems; clear hierarchies (organizational, reporting); practical IPAC policies, standards and requirements; inspection, monitoring and auditing systems; processes and protocols; and education, training and instruction. So, what can be done?

There are several ‘low hanging fruit’ items that can be implemented to help start building (or re-building) culture, such as defining clear IPAC policies, requirements and protocols; proactively participating in, and contributing to, multi-disciplinary meetings (where setup); directly engaging and working more collaboratively and openly with IPAC practitioners before facility management work commences; inviting practitioners to participate in planning strategy meetings; and properly communicating with involved healthcare facility stakeholders. Building a positive IPAC culture takes work but it is necessary to protect those most vulnerable to infectious disease.

This requires leaders to lead and others to step up, stakeholders to positively work with one another, and respect and commitment to maintaining and even improving patient outcomes. After all, when healthcare facilities lose sight of the mission of protecting occupants, it can only detract from keeping those in their care safe. Craig Yee, founder of Infection Control Training Group, is an industrial hygienist and infection control expert with nearly 20 years’ experience. He has assisted many stakeholders on more than a dozen healthcare facility projects with identifying and managing their infection risks. Craig can be reached at 604-428-8782 or craig@ictg.ca.

OVERCOMING OBSTACLES Several things can interfere with creating and establishing a long-lasting, positive infection prevention and control (IPAC) culture. These include: Leadership • Who is in charge? • How/when are decisions made? • What values, beliefs, perceptions are reinforced? • How do leaders get buy-in?

People • What people are required? Who is in place and engaged? • What are their daily behaviours and actions? • What level of education and training is needed?

Management • How is IPAC managed within the organization? • How are stakeholders supported and empowered? • Are managers consistent in executing their IPAC duties?

Mission, Vision and Values • What is the IPAC mission and vision? • Are messages clear and consistently and widely communicated to involved stakeholders? • Are key messages understood?

Workplace Practices • What protocols and practices exist? • What has been done? What more is needed? • How is performance tracked and managed?

Work Environment • What is the current workplace status? Does it promote positivity and collaboration? • Does it facilitate and support proper IPAC? • What are past and prevailing culture challenges, obstacles and issues?

Policies and Philosophies • What are the prevailing beliefs? • What policies have been established? Are they being consistently followed? • What actions and behaviours are allowed and condoned?

Communications • Are systems and reporting hierarchies in place? • What are the communication measures and means? • Are messages clear, transparent and honest?

SUMMER/ÉTÉ 2020 31

ANATOMY OF AN ISOLATION ROOM Design criteria, requirements to ensure AIRs control spread of infectious diseases By Jessica Fullerton & Nick Stark

he inadequate number of rooms and treatment spaces for people presenting with airborne diseases has been highlighted in recent months as facilities struggle to appropriately place COVID-19 patients receiving aerosol generating medical procedures. The virus is known to be transmitted via contaminated respiratory droplets; however, there are several medical procedures that result in the formation of aerosols that render patients and staff in need of the protection offered by an airborne isolation room (AIR). In order for 32 CANADIAN HEALTHCARE FACILITIES

these spaces to function properly, there are a number of associated room and system requirements that need consideration. EVOLUTION OF AIR DESIGN

Compliant AIRs can be a struggle for older facilities, many of which have been grandfathered in with nominal airflow and minimal pressure differential so they act more as segregation rooms than true air barriers. These rooms were designed at a time when the risk of airborne transmission was not well understood. Switchable modes were

typical, presenting a significant safety risk should the room be left in the wrong pressure mode. Dedicated exhaust systems were uncommon, posing a risk to occupants exposed to contaminated recirculated air. Continued biological understanding of these pathogens has translated into the improved safety of these rooms. The 2001 edition of CSA standard Z317.2, Special Requirements for Heating, Ventilation and Air-Conditioning (HVAC) Systems in Health Care Facilities, contained some specific requirements for AIRs,

INFECTION PREVENTION & CONTROL

but it was the SARS epidemic of 2003 that heightened concern and awareness of the potential risks associated with the airborne transmission of novel microorganisms. Minimum pressure differentials based on inward directional airflow and higher air change rates were established. HVAC and infection prevention and control standards and guidelines have since further evolved, expanding on requirements for the presence of anterooms, minimum pressure differentials, dedicated exhaust systems, monitoring and alarms. Experiences with SARS, the current COVID-19 pandemic and the re-emergence of diseases such as tuberculosis and measles have increased awareness about the severe lack in number and ability of these rooms to safely house patients, particularly in older facilities. SPECIAL PRECAUTION SPACES

Definitions and design requirements of an AIR, protective environment room (PER) and combination AIR/PER have been

clearly laid out in recent standards; however, there still seems to be an element of confusion among designers and facility owners alike. Air pressure and directionality are extremely important, and the requirements for both are dependent on the purpose of the room. AIRBORNE ISOLATION ROOMS

The design criteria for an AIR are 12 air changes per hour and 7.5 pascals (Pa) of negative pressure. Other design elements include low-level exhaust near the head of the patient bed and non-aspirating diffusers. Dedicated exhaust from the patient room, washroom and anteroom is required, with discharge a minimum of three metres from the top of the roof and 25 metres from any air intake. If this discharge height cannot be accommodated, high efficiency particulate air (HEPA) filtration of the exhaust air is required. AIRs need to be designed and constructed to a higher level of airtightness, with consideration for pressure testing during construction to verify effectiveness of

sealing techniques. Particular attention should be paid to conduits and lighting fixtures as these are problematic areas of air leakage. Sliding glass doors provide ease of use when the room is not utilized as an AIR; mechanical problems with the door itself, uneven floor issues and air leakage have been complications with use. The mandatory requirement that all AIRs be equipped with anterooms is a recent update to CSA Z8000, Canadian Health Care Facilities. Evidence in support of anterooms includes: more control against unwanted air movement; reinforces user identification of the AIR as a specialized environment; provides an enclosed space for donning and doffing of personal protective equipment; and adds safety in the management of unknown or emerging diseases, as well as consistency across functions and facility types. Anteroom pressure must be negative relative to the corridor and positive relative to the isolation room. Location within the facility and impact SUMMER/ÉTÉ 2020 33

INFECTION PREVENTION & CONTROL to patient care must also be taken into consideration during various planning phases. AIRs are often stacked in order to share HVAC systems but this can result in performance issues. This can be mitigated as long as appropriate airflow controls are in place so the operation of one room does not impact another. PROTECTIVE ENVIRONMENT ROOMS

PERs are typically used for severely immunocompromised patients (for example, allogenic stem cell transplant recipients or patients with prolonged neutropenia). These rooms require 7.5 Pa positive pressure to corridor and 12 air changes per hour with HEPA filtered supply air. Like AIRs, PERs require anterooms but these are positive relative to the corridor and negative relative to the patient room with nine air changes per hour. The number and location of these rooms depends on the patient population and services provided; they are most commonly included in cancer centres, transplant and burn units. Recently, PERs have also been considered for intensive care units and outpatient environments servicing immunocompromised populations. A SAFE COMBINATION

Combination AIR/PER rooms are utilized for immunocompromised patients that are also affected by an infectious disease (for example, a bone marrow transplant patient who also has tuberculosis). These specialized rooms require an anteroom, as well as a unique direction of air movement. The anteroom is maintained negative to both the patient room and corriBiomedical_CHF_Winter_2017_FINAL.pdf dor (air must flow from the patient room1 and corridor into the anteroom). All air removed from the anteroom, patient room and washroom is exhausted to the outdoors, similar to an AIR.

OTHER DESIGN CRITERIA

PANDEMIC PLANNING

All three types of isolation rooms require locally and centrally alarmed pressure monitoring devices. With several devices on the market, consideration should be given to ease of use and standardization across the facility. The importance of involving the clinical team cannot be overlooked as there are patient care implications to the design of these rooms. For example, patient room doors must always be closed to maintain pressure differentials, which can be an issue for clinical line of sight. Windows in doors may need to be incorporated. As patients who occupy these rooms rarely leave them, large windows and a pleasing view to the outside are desirable.

Recent experience with COVID-19 has tested pandemic planning processes. The ability to isolate sections of a facility such as an inpatient unit to cohort infectious patients in negative pressure pods or outbreak control zones has proven benef icial. Considerations include: self-contained with a secure boundary; negative pressure condition with respect to adjacent floor areas; all air exhausted with no recirculation; entry area contains a space that can be converted into an anteroom with hand hygiene sink; pressure monitoring and alarms; and pre-programmed into the building management system. Decisions concerning type, number and location of isolation rooms should be made strategically, using a multi-disciplinary approach in an attempt to balance staff and patient safety, cost, routine use and future needs. In planning for future outbreaks and/or epidemics or pandemics, it will be crucial to incorporate lessons learned from current experiences with COVID-19.

MULTI-MODAL PRESSURE SYSTEMS

Current challenges with COVID-19 have highlighted the need for an operating room (OR) for patients presenting with airborne diseases. The aim should always be to provide a safe location with appropriate engineering controls to perform aerosol generating medical procedures (like intubation in an AIR), followed by transfer to a protective, positive pressure room. This space should be treated as a combination AIR/PER — a positively pressurized OR with an anteroom that is negative to both the occupied corridor and OR. Acting as an air-lock for stretchers, the anteroom should have a minimum internal length of 2.4 metres. There has been resurgent consideration of pressure critical rooms that can switch 2017-10-23 4:45 PM pressure modes. This is currently not permitted under standards Z317.2 and Z8000, given the immense risks (human error, infection of immunocompromised patients and system calibration, to name a few).

Jessica Fullerton is the construction lead with the infection prevention and control department at the Ottawa Hospital. She is chair of CSA standard Z317.1, Infection Control During Construction, Renovation and Maintenance of Health Care Facilities. Nick Stark, P.Eng., is vice-president of knowledge management at H.H. Angus and Associates Ltd. Consulting Engineers. He has been involved in hospital design for more than 40 years and is chair of CSA standard Z317.2, Special Requirements for Heating, Ventilation and Air-Conditioning Systems in Health Care Facilities. Jessica and Nick can be reached at jfullerton@toh.ca and nick.stark@hhangus.com, respectively.

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