Preparedness

By Wayne Hansen

The emergency department is the first place where a hospital will know that it may be facing a cluster of disease cases or an outbreak. People classified as walk-in patients trickle in. In a true outbreak, the number of ED department patients escalates rapidly, often catching a hospital off guard. The whole issue of providing proper environment of care for patients during a possible pandemic is too complex for any one department of a hospital to prepare for alone.

The first step is to establish a team or committee that can address these issues. The team should include representatives from infection control, materials management, nursing management, employee health and safety, and facilities engineering. If a hospital has a person dedicated to risk management, then that individual also should be included.

Once the team has been formed, it needs to plan for an additional level of care for the ED admitting staff. Planning can consist of steps as simple as:

Ensure proper personal protective equipment (PPE) is available to ED staff. They need to have items such as N-95 respirator masks, gloves, safety goggles; and it is a good idea to have at least one HEPA-filtered, air-supplied respirator. This type of respirator is much more comfortable for the staff to use, or for a patient if it is determined that the patient needs to be masked.

This type of device can be used for men with facial hair as well, where the N-95 cannot.

Ensure air flows from the staff area to the incoming patient area. It doesn’t help the situation to have hospital staff infected by patients. Facilities engineering needs to conduct a simple air balance check to ensure that staff is protected, and if the airflow is found wanting, corrections are generally simple. The most effective form of protection is to make simple modifications to the air distribution system in the area.

Once a patient has been diagnosed and found to have a communicable disease, such as a severe form of influenza, staff should isolate that patient. After a patient is masked, the individual should be quarantined in a room that protects other patients and staff.

If a hospital has sufficient negative isolation rooms, then this is not a problem, as long as the number of patients doesn’t exceed the available isolation space.

The real problem confronting the health care industry is that most hospitals don’t have the necessary isolation rooms for more than a few patients, which means that hospitals will have to provide temporary emergency isolation areas.

A second problem can surface when a patient is diagnosed with a communicable disease and also is immunocompromised, such as a person undergoing chemotherapy. In this instance, the patient would need to be isolated from the hospital to protect both the hospital and the patient.

There are three types of isolation rooms defined by the CDC: the normal negative isolation room, the airborne infection isolation (AII) room and a combination room. All of these applications are shown with an anteroom, which many facilities do not have.

Many facilities have a negative isolation room without an anteroom. A frequent mistake made by nursing staff is that when this type of room is used for an infected patient, medical staff feels safe to enter, then gowning just inside the door.

A study conducted by Farhad Mem-arzadeh, chief of technical resources, Division of Engineering Services, the National Institutes of Health (NIH), Bethesda, Md., states that the only safe way to gown is in the corridor prior to entering a quarantined room.

Isolation capacity in our health care system is a vital concern. It is estimated that the United States has less than 60,000 AII rooms available nationwide.

The CDC forecasts that the patient hospitalization need as a result of an influenza outbreak could reach 15 million. This scenario presents our health care system with a challenge that cannot be met with current hospital isolation capacity.

If we assume that a given facility has exceeded the number of fixed isolation rooms available, and that there are going to be additional patients who should be isolated, then a facility must have a program in place to deal with this event.

Since this program will involve minor changes to current room use, the team has to coordinate its strategic planning.

Prepared and equipped

There are portable temporary containment devices commercially available that can be used to convert a standard patient room, or even a patient wing, into an isolation facility.

This particular unit can easily be set up and taken down. It collapses into a package about the size of an oversized golf bag, and is easily rolled from storage to any area of the hospital.

Many hospitals already have purchased equipment such as this through Rockville, Md.-based Health Resources and Services Administration (HRSA) grant applications. For those that haven’t, the team should contact the hospital’s HRSA coordinator.

The selection and number of  devices to be purchased is primarily a facilities department function, but also must include input from the infection control practitioner and materials manager.

The equipment shown was designed to help manage either singular or mass patient isolation needs in a hospital.

This technology is easy to understand and use and provides protection against the spread of airborne infections. When properly used, the protection extends to patients, health care providers and visitors.

The team must evaluate various areas of the hospital for potential temporary isolation. Several potential sites should be  discussed, ranging from a room for one or two patients, to an area capable of housing 20 patients.

The team needs to evaluate each of the possible areas selected for the following:

Medical staff and nursing access to patients and necessary support activities.

Location for PPE, disposable coveralls and waterless hand sanitizer. In many cases, there won’t be wall-mounted waterless hand sanitizer canisters available, so small bottles will be the most convenient method of meeting this requirement.

Ability to easily bring in a crash cart if needed and close access to medications.

Facilities engineering will have to evaluate each area with respect to the supply air capacity, return air capacity and exhaust air capacity. This information is critical to the development of the isolation plan because the negative air machines will have to overcome the supply air sufficiently to provide for the proper isolation environment. The following three examples will provide a simple basis to assist in the definition of application:

1. Setting up a typical, single-patient room

A typical single-patient room is designed with an approximate floor area of not less than 125 square feet, and has a ceiling height of some 8 feet, totaling a volume of 1,000 cubic feet. For current isolation patient health needs, the design codes require a minimum air exchange rate of six times per hour (6-ACH) for existing airborne infection isolation rooms, which is 6,000 cubic feet of air per hour.

To achieve this exchange rate, 600-CFM negative air machine will be needed to provide enough negative pressure to meet these health code requirements. Once the equipment has been set up and tested by engineering, then a materials manager will need to locate the PPE and clean coveralls, along with a covered bin for the used coveralls and equipment. Typically this is done on a cart located adjacent to the air lock unit so they are readily available to clinicians prior to entry.

2. Setting up a four-patient room

A typical four-patient room is designed with an approximate floor area of not less than 250 square feet, and also has a ceiling height of 8 feet, totaling a volume of 2,000 cubic feet. To achieve the 6-ACH requirements, 12,000 cubic feet per hour must be exhausted. A single 1,200-CFM negative air machine will comfortably satisfy these health code requirements, or depending on the exact set up, two units of 600-CFM may be used. The same attention to PPE needs as shown above applies.

3. Setting up a room for 16-20 patients

This could be part of a patient wing, or any hospital space designed to accommodate this many patients and will have an approximate floor area of 5,000 square feet (including support areas) and also a ceiling height of 8 feet totaling a volume of 40,000 cubic feet.

For this example, 240,000 cubic feet per hour must be exhausted to meet the 6-ACH requirements. This will most likely require portable isolation units at each end of the space to provide sufficient health care worker access to patients.

Each location will require negative air machines capable of providing a total of up to 24,000-CFM, depending on the amount of dedicated exhaust already available in the space. The photo on page 31 shows a containment device for large areas such as this. Materials management will have to establish a PPE cart at each air lock unit, along with the disposal bin.

Nurse management will present the program to the charge nurses and supervisors and provide training after the program has been finished and accepted. This is crucial because the floor nurses are  patients’ first line of contact and the team’s eyes and ears on the floor. While the nurse manager has the primary responsibility for training, all team participants should take part. It’s essential that the medical and nursing staff understand how the various members of the team function within the program, and which individual should be called if questions arise. Training elements can include a complete overview of the program with as much detail as the team deems appropriate, but the following elements are mandatory:

An overview in nonengineering language as to the function of the anteroom unit and the attendant negative air machine. The static pressure gauge on the side of the negative air machine will be read daily by the engineering department, but charge nurses should also be familiar with how to read this gauge and what it means.

Checking the seals around the anteroom unit that connect the unit to the doorframe. Again, this is an engineering function, but nurses should also be familiar enough with the installation to tell when something is amiss.

The PPE cart is primarily a materials management function, but nurses should be familiar with what supplies should be there, know when to call for additional materials, and when to notify materials management of any problems.

The type of training will be dictated by the team, but many facilities have found it beneficial to show staff how equipment is set in place and, at the same time, describe what areas should be monitored. This type of demonstration training has been more easily understood and time efficient than a formal training seminar and PowerPoint presentation. The training should be documented, and a roll of attendees taken for inclusion in the hospital’s training manual.

Team members should write their own scenarios, if possible keeping them to one or two pages. Keep these scenarios in a notebook, and present it to Joint Commission surveyors at the next survey. In some cases, these documents and any follow-up document created after an infectious disease event qualify as a Performance Improvement Project.

Once the potential areas have been selected, a work plan sheet must be developed. This in essence, defines the area with respect to the number of patients to be accommodated, the total amount of supply air to the space, and the amount of additional exhaust to be provided by negative air machines. Any return air grilles in the space must be sealed with flame-rated plastic film to prevent con-tamination of the common air conditioning system. Dedicated exhaust grilles that discharge directly to the outside may be left active. If it isn’t convenient to route the discharge from the negative air machine to the outside, the CDC allows for the HEPA-filtered air to be discharged into the corridor outside the quarantined area.

The air being discharged from these HEPA-filtered fan units is of the same quality as air supplied to a bone marrow transplant unit.

A distinction must be made regarding the type of filters in the negative air machines. If patients have been diagnosed with a communicable bacterial infection or SARS, standard HEPA filters are suitable for this application. For other viral infections, such as virulent influenza, ULPA filters must be used. The ULPA filters are more costly than HEPA filters, so it is critical that the medical staff provide accurate information to the team.

The question arises as to how long the filters can be used in the machines. That depends on the decision of the infection control practitioner (ICP). Most equipment manufacturers will suggest that filters be removed and bagged as medical waste after the quarantine zone is disassembled; and many ICPs support this method.

There are some mitigating factors, however. Some negative air machines have ultraviolet germicidal irradiation lamps at the inlet of negative air machines that kill most bacteria and viruses as they pass through and become trapped on the incoming face of the filter.

Because of this process, some will argue that the filters can be reused after a unit is cleaned. Again, this decision must be made by individual facilities.

Logging airflow

After a quarantine zone is set up and tested for proper airflow, a log sheet must be placed on the outside of the unit to properly monitor and document airflow. As part of the documentation process, a photograph should be taken of the setup.

The medical and nursing staff entering the patient quarantine area must don and take off gowns outside the temporary anteroom, just as they would for a conventional negative isolation room without an anteroom.

Following the event, a negative air machine should be sealed on both intake and discharge ends and removed to a secure area for thorough cleaning before storing it for the next use.

The portable isolation chamber should be subjected to the same terminal cleaning process as the patient care area and stored for future use.

Some facilities that have purchased this type of equipment as part of the HRSA’s program for hospitals use it on a daily basis for isolating construction and remodeling projects. If this is the case, it is recommended that at least two units be held in reserve strictly for infectious disease uses.

Following cleanup, it is important to review the log sheets and any other documentation developed during this event. Gather all documentation, including any photographs taken, and place it in the event binder to have ready for the next Joint Commission survey.

Hospitals that have already established a program for emergency uses have reported a reduction in reported hospital-acquired infections.

Anytime a patient outcome can be improved, everyone wins; and this is one simple technology that can have a beneficial effect on the final outcome.  

Wayne Hansen is a registered mechanical engineer in seven states and a registered environmental assessor. Hansen has written several articles and books for the health care industry.

Isolation unit and negative air machine monitoring log

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