The detail level of this guide has been created to support healthcare facility contacts.
For a guide structured to support facility and healthcare administration, view our Long-Term Pandemic Considerations for Healthcare Facility Design Guide.
With the residual impact and the changing needs of the market environments we support − workplace, industrial, learning, healthcare, science + technology, living and community − we continue to refine our approach, services and solutions. With safety and well-being at the forefront of these industry sectors, we are researching, innovating and sharing ideas on how we can deliver design solutions to support our clients’ unique and evolving needs.
Our design experts are asking probing questions to achieve desired flexibility, quantify capacities and assess technologies that deliver forward looking and high- performing design solutions. At EUA, we are passionate about what we do. We believe that design has the ability to elevate people’s potential. Now, more than ever, our pace of innovation remains ready to serve our clients.
Table of Contents
(click on the sections or questions below to jump directly to it)
3. Walk-ins with some COVID-19 symptoms present at the front desk of Urgent Care or Emergency Department: What are best practices to assess these patients and how can the facility be used / modified to assist these walk-ins?
Every healthcare system has been preparing for a pandemic. Each system has an All-Hazards Approach Emergency Preparedness Response Plan that is updated annually. While preparing this plan, a risk assessment addressed each potential hazard: flood, tornado or pandemic. Some facilities have been updating their emergency response plans immediately after the start of this pandemic and continue to adjust daily.
A pandemic challenges hospital leadership to make time-sensitive, critical decisions about clinical operations and resource allocations. Pandemic-induced strains on capacity far exceed routine peak demand. Even with computer models, when a pandemic will peak can’t be predicted within a narrow range of certainty.
- To anticipate important questions and seek answers which summarize recently gained insights and that reflect best practices. As the healthcare industry redirects their attention to focus on pandemic response, EUA, as healthcare design market leaders, will need to answer questions and support our responses with convincing logic and credible references.
- To gather information that will be most useful to serve our existing healthcare clients with their urgent immediate need to best utilize and to rapidly adapt their existing facilities. To this end, there has been emphasis on solutions that would be appropriate within the State of Wisconsin. We feel that this research is applicable today, during a possible rebound of the current pandemic, as well as the next future pandemic.
- To summarize strategies for appropriately utilizing (and adapting as necessary) existing facilities for safety of patients, doctors, nurses, first responders and everyone else who enters a healthcare facility. There is a need to adapt and use healthcare facilities that were not originally designed for a pandemic surge. They do not easily pivot to support the infrastructural changes required at this scale.
- Facilities must quickly adapt inflexible spaces, creating site-specific guidelines that are adherable and implementable based on the best available knowledge. This involves adapting to site-specific conditions while capturing quick spatial interventions that have been shown to work.
- Facilities as-designed along with infection control protocols have been found inadequate for COVID-19. Validated protocols specifically designed to prevent COVID-19 transmission did not yet exist at the beginning of this pandemic; therefore, immediate spatial redesigns, have been based on what was learned from other diseases, such as Ebola and tuberculosis.
- To summarize best practice strategies that will make the best of non-ideal existing conditions as well as improvements that can be made to the built environment to improve the ability to care and to support healthcare providers on the frontlines. These include technologies, innovations or adaptions that are needed to minimize risk and improve outcomes.
- To inform EUA’s Healthcare Studio to better assist our clients with this current focus. We believe a healthcare building’s design may play a critical role in prevention, preparedness, resilience and recovery.
Not in Scope:
Since this research effort is focused on short-term, immediate adaptions of healthcare facilities, it excluded long-term questions like “Design Implications of COVID-19 on Healthcare Facilities of the Future.” This is being addressed in another EUA research effort, which can be found at this link: https://www.eua.com/media/8861/COVID-19-planning-impacts.pdf
Alternative Care Sites (ACS):
Adaptive reuse of non-healthcare buildings into temporary healthcare facilities has been a significant strategy, such as the following:
- Initial projections indicated that New York City would need tens of thousands of additional hospital beds for COVID-19 patients. The U.S. Army Corps of Engineers installed beds in convention centers (more than 2,000 beds were planned).
- Several cities have addressed the surge in demand with rapidly assembled “field hospitals.” Other temporary facilities have gone up in Los Angeles, Chicago and Detroit.
- Repurposed decommissioned structures as a large-scale coronavirus testing center, vacant office shell space and gymnasiums with cots and dividers. CSM Waiver in effect since March 1, 2020: CMS will permit non-hospital buildings to be used for patient care and quarantine sites, provided that the location is approved by the State.
- Wisconsin State Fair Exposition Center, a 200,000-square-foot building, was transformed into a 754-bed care facility for low acuity patients. Design, procurement and construction of the facility was completed in 10 days and was led by the U.S. Army Corps of Engineers. Bathrooms were constructed in the middle of the hall for patient use, showers were also installed. Oxygen lines were installed for patients that may require 24/7 oxygen (Milwaukee Business Journal, 2020, retrieved from https://www.bizjournals.com/milwaukee/news/2020/04/20/see-inside-COVID-19-alternate-care-facility-at.html).
Sources of information included online articles, webinars, a telephone survey created to contact clients firsthand and a large healthcare system’s COVID-19 preparedness response plan which was utilized to distill generic ideas. Also, we engaged our HVAC consulting engineer of choice to review and comment on HVAC related information.
A Question/Answer format was selected so that the reader may skim to the Question/Answer that resonates with their immediate interest, without having to read the entire page. As design professionals, we’re interested in physical, spatial, functional solutions; therefore, we’ve organized information under headings of functional areas, as follows:
- Diagnostic Testing
- Urgent Care and Emergency
- Healthcare Waiting Rooms
- Patient Rooms
- Staff Sleeping Rooms
- Procedure / Operating Rooms
- Compounding Pharmacies
Beyond the list of functional areas, we have a separate heading to address Flows Between Rooms.
Virtual Telehealth Visit:
- Direct patients to virtual channels as a first stop. If a patient has symptoms of COVID-19, they can schedule a contactless visit to find out if they should be tested. Evaluating patients remotely avoids risks of contagion for the office staff and providers. Shifting appointments to telehealth visits when possible proactively manages capacity.
- Patients deemed stable with milder presentations of COVID-19 can be followed and monitored at home with serial telehealth visits.
- Furthermore, patients with ongoing chronic conditions who are at high risk for complications from COVID-19 infection could be provided with needed care via telehealth in the safety of their homes.
- COVID-19 has transformed telehealth from a “nice-to-have” program into an essential element of care delivery. Parallel demands to limit patient travel, prevent potential exposure and preserve clinical capacity all have telehealth as a solution. The sudden attention from providers, payers and consumers will also have enormous consequences for telehealth adoption in the future (Rabinowitz, 2020, retrieved from https://www.medicaleconomics.com/authors/betty-rabinowitz-md).
- Use of smart algorithms conducting conversation via auditory or textual methods are becoming more widespread. These talking or texting smart algorithms might become the first contact point for primary care. Patients who may not get in touch with medical professionals with every one of their health questions may turn to chatbots first. If the chatbot cannot respond to the raised issues, it will transfer the case to a real-life doctor. In a pandemic, chatbots may offload time-consuming, but important instructions from human healthcare workers (The Medical Futurist, 2020, retrieved from https://medicalfuturist.com/top-12-health-chatbots/).
Minimize Chances for Exposure:
- Cancel group healthcare activities (e.g., group therapy, recreational activities).
- Postpone elective procedures, surgeries, and non-urgent outpatient visits.
- Recommend that patients with respiratory symptoms and fever call the office before arrival.
- Limit points of entry and manage visitors to reduce spread of infection. One clinic, for example, had all entrances locked down except for one for patients and another for staff. Patients were provided with a mask immediately upon entering before being tested.
Locate Triage Stations Outside Healthcare Facilities:(Screen patients before they enter.)
- Creating a triage perimeter around the hospital and directing any patient with fever or respiratory symptoms to a dedicated tent or entrance helps keep the emergency department as COVID-19 free as possible. There are several approaches to set up separate, well-ventilated, triage areas:
- One strategy is to use an ancillary building at the healthcare campus as a “designated respiratory virus evaluation center” for patients with fever or respiratory symptoms.
- As an example, one facility utilized a temporary tent to triage patients. The tent was placed outside the building entrance; however, it did not work well in snowy weather. They soon switched to a temporary trailer in the same location. Hand-held, portable, two-way radio transceivers were used for communication between staff.
- A variation of this strategy is obtaining a temporary prefabricated building to expand triage / assessment space and have it ready for future responses either onsite or at some offsite location.
- Another facility added an expansive, secured, drive-through ambulance entry. It is sealed off by overhead doors for ingress and egress. Incoming patients are assessed while still within this entry.
The Singapore Model: Planning concepts generated from lessons learned during the outbreak caused by SARS-CoV-1 in 2003.
- A separate entrance for fever-ridden patients is an intermediate entry between the emergency ambulance entry and the walk-in entry. The separate “fever entry” leads directly into an isolation compartment with four types of isolation rooms:
- Regarding the Singapore Model’s concept of “fever entry” the Center of Disease Control (CDC) cautions that “Fever may not be present in some patients, such as those who are very young, elderly, immunosuppressed or taking certain medications. Clinical judgement should be used to guide testing of patients in such situations.”
- The department can be locked down by zones to help prevent the spread of infectious diseases. The corridors act as pressurized buffer zones to assure no transfer of contaminated airflow. There is 100% redundancy in air-handling units, power and medical gases to enable shutting down half of any one compartment to perform terminal cleaning.
(Lonescu M, 2020, retrieved from https://www.bdcnetwork.com/blog/its-not-if-when-designing-healthcare-spaces-support-pandemic-response).
- Mode of transmission believed to be primarily through close exposure to respiratory droplets produced when an infected person coughs, sneezes or talks. Airborne transfer over long distances is unlikely.
- It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose or possibly their eyes, but this is not thought to be the main way the virus spreads.
- Isolate symptomatic patients as soon as possible in an exam room with the door closed, at least 6-feet from other people. (Therefore, the negative pressure exam room component of the Singapore Model is not required per CDC recommendations.)
The World Health Organization (WHO) explains:
- The [respiratory] droplets land on objects and surfaces around the person. Other people then catch COVID-19 by touching these objects or surfaces, then touching their eyes, nose or mouth.
- These droplets are too heavy to hang in the air. They quickly fall on floors or surfaces. It is not certain how long the virus that causes COVID-19 survives on surfaces, but it seems to behave like other coronaviruses. Studies suggest that coronaviruses may persist on surfaces for a few hours or up to several days. This may vary under different conditions (type of surface, temperature or humidity of the environment).
- The “incubation period” means the time between catching the virus and beginning to have symptoms of the disease. Most estimates of the incubation period for COVID-19 range from 1-14 days, most commonly around five days. These estimates will be updated as more data become available.
Assumptions in Flux:
- Assumptions are different today than they were on Day-1 of the pandemic. Assumptions will likely be different at the end of the pandemic. One recent study provided a weight of evidence that aerosol transmission is an important pathway of COVID-19 transmission. The absence of symptoms of coughing and sneezing in asymptomatic individuals turns attention to aerosol transmission. Asymptomatic individuals infecting others through normal breathing and talking produce droplets predominantly <1 µm that are subject to aerosol transport. Recorded aerosolized COVID-19 particles that remain suspended in the air for hours and are subject to transport over long distances (up to 13-feet) including outside of rooms. These studies suggest further exploration of appropriate measures to curb inhalation exposure to small aerosols, including 5 µm or less, within buildings, where they may travel and settle (Anderson E, et al, 2020, retrieved from https://onlinelibrary.wiley.com/doi/full/10.1111/risa.13500).
- American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), through its Environmental Health Committee, created the Epidemic Task Force and has issued the following statements:
- Transmission of COVID-19 through the air is sufficiently likely that airborne exposure to the virus should be controlled. Changes to building operations, including the operation of heating, ventilating and air-conditioning systems, can reduce airborne exposures.
- Ventilation and filtration provided by heating, ventilating and air-conditioning systems can reduce the airborne concentration of COVID-19 and thus the risk of transmission through the air (ASHRAE, Environmental Health Committee (EHC) Emerging Issue Brief: Pandemic COVID-19 and Airborne Transmission, 2020, retrieved from https://www.ashrae.org/file%20library/technical%20resources/COVID-19/eiband-airbornetransmission.pdf).
Drive-up Testing at Urgent Care:
- Some healthcare systems have incorporated drive-up COVID-19 testing for their urgent care centers. If warranted by a virtual visit, patients receive an appointment for a drive-up test. Essential workers without symptoms may schedule tests, as well.
- Those deemed seriously ill can be referred to the emergency department with prior notification of their arrival.
(Retrieved from Design Institute for Heath, https://static1.squarespace.com/ static/5a7f5d63e45a7c1f4ef0d7a7/t/5eaadcd32ff52116d10120ce/1588255980126/COVID-10+DriveThru+Testing+Guide+V3.pdf).
Universal Testing at Hospitals:
- Test all patients admitted to hospital for COVID-19, as well as any patient scheduled for surgery, regardless of whether they have symptoms. Preparing for screening of every patient and worker who enters a facility is critical. Patients are admitted to designated units based on their test results.
- Technology used to assist with temperature testing includes infrared cameras within building entries and thermal monitoring through closed circuit television to detect potential risk even before entering the building. Temperature testing on entry, which earns an “I was screened today” sticker, is a visual reminder that everyone must be checked.
- Automated hand hygiene monitoring systems using electronic and computerized technology can monitor hand hygiene performance 24/7 on all shifts without observer bias. The systems can remind caregivers to wash their hands at the right place and at the right time. Systems track individuals, hand wash sinks and performance through sensors installed in dispensers and in wristbands worn by healthcare providers. Location beacons installed in patient rooms monitor hand hygiene opportunities and a gateway sends all the data to a cloud database. A reporting system accessible via a mobile app and the web shows how often, how long and how well individuals are washing their hands and provides feedback and reminders for hand hygiene (Vitalacy, 2020, retrieved from https://3e664d24-0e2e-4603-bd76-9e6684827e38.filesusr.com/ugd/9a721a_842dba903f6c4c65b156a0da981ee748.pdf).
Urgent Care + Emergency
3. Walk-ins with some COVID-19 symptoms present at the front desk of Urgent Care or Emergency Department: What are best practices to assess these patients and how can the facility be used / modified to assist these walk-ins?
Assume that every patient is potentially infected with a pathogen that could be transmitted in a health care setting. Consider the following occasion: some patients who have presented at the Emergency desk for a totally unrelated ailment were tested for COVID-19 with positive results. Another patient presented with abdominal pains, no cough, fever, shortness of breath or other body aches. However, these other symptoms developed during the time the patient was sitting in the waiting room chair.
For patients with COVID-19 symptoms, they should be isolated in compliance with CDC and Department of Health (DOH) guidelines as soon as possible to limit the spread of the virus:
- Set up separate, well-ventilated triage areas. Place patients with suspected or confirmed COVID-19 in private rooms with the door closed and with private bathrooms (if possible).
- Actively screen patients and visitors for symptoms of acute respiratory illness (e.g. fever, cough, difficulty breathing) before entering your health care facility.
- Assist in monitoring and restricting access for visitors and other nonessential personnel.
- Implement source control for everyone entering a health care facility (e.g. all visitors, patients and staff entering) regardless of symptoms. For visitors and patients, a cloth face covering may be appropriate. If a visitor or patient arrives to the healthcare facility without a cloth face covering, a facemask may be used for source control if supplies are available. Encourage patients and visitors to wear cloth masks when visiting to prevent transmission from non-symptomatic individuals.
- Healthcare workers don with proper use of personal protective equipment (PPE) including eye protection.
- After delivering care, exit the room as quickly and directly as possible (i.e. complete documentation in a clean area).
- Conduct an inventory of available PPE, utilize sanitation and handwash stations and encourage sick employees to stay home (American Academy of Family Physicians, 2020, retrieved from https://www.aafp.org/dam/AAFP/documents/patient_care/public_health/COVID-19%20Office%20Prep%20Checklist.pdf).
Healthcare Waiting Rooms
Healthcare organizations with multiple locations have chosen to designate certain facilities to solely seeing patients with suspected COVID-19, designating other facilities to see patients for ongoing chronic and acute non-COVID-19 issues. This separation reduces the likelihood of patients with respiratory infectious symptoms sharing the waiting room with others.
Some practices have invited patients, if they are medically able, to wait in their cars in the parking lot until they receive a text when the exam room is available for them, removing the need for the waiting room. This strategy also addresses patients who may be anxious within waiting rooms even with distancing (Rabinowitz, 2020, retrieved from https://www.medicaleconomics.com/authors/betty-rabinowitz-md).
A temporary no visitor policy will reduce the number of people in facilities and the risk of exposure between patients, visitors and staff.
Consider arranging a separate entrance for symptomatic patients. Post signs at entrances and in waiting areas about prevention actions. For signs and infection prevention guidelines see: (CDC, 2020, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/preparedness-checklists.html).
Rates of staff infection were lower than expected after a facility instituted the following policies:
- Hand sanitizer was placed at each entrance and everyone was asked to sanitize their hands when they entered the building.
- A staff member was placed at the entrance to ask patients about their symptoms. Procedures were implemented to quickly triage and separate suspected COVID-19 patients in a private room.
- Face masks were available at each entrance and everyone was asked to wear one while in the facility.
These policies resulted in patients who were not only willing to come in for care, but were also confident that they were at one of the safest facilities at which to receive care. (CDC, 2020, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinic-preparedness.html).
At the reception desks, install transparent shields to limit close contact between staff and potentially infectious patients. Provide markers on the floors to show where people should stand for check-in and check-out. The staff wear masks, type determined by the care that they provide, to best ensure both their safety and the safety of patients (Michigan Medicine, The University of Michigan, 2020, retrieved from https://www.uofmhealth.org/coronavirus/keeping-patients-safe).
Deep cleaning: During the COVID-19 pandemic, emphasize deep cleaning of waiting rooms, including all frequently touched surfaces. After patients leave, clean frequently touched surfaces using EPA-registered disinfectants.
- Reception counters
- Check-in kiosks and iPad screens
- Waiting room chairs (Use chairs that can withstand disinfection.)
- Elevator buttons
- Door handles
Discontinue the use of toys, magazines and other shared items in waiting areas. Likewise, discontinue the use of office items shared among patients, such as pens, clipboards, phones, etc.
Seating arrangement: Arrange seating conducive to patients maintaining at least six feet of distance from other patients. People who arrive together from the same household can sit closer. This provides an opportunity to provide:
- More chairs with direct sight lines to information sources
- More space to place personal items
- Enough space to be separate from strangers (but close to family members to encourage interactions)
- Use freestanding transparent room dividers to separate seating groupings (Ossmann, M, 2020, retrieved from https://www.beckershospitalreview.com/patient-flow/how-are-waiting-rooms-tied-to-patient-experience-5-key-findings.html)
In Wisconsin, as of May 29, 2020, COVID-19 data summary included 17,707 cumulative positive tests, 659 currently hospitalized, 138 of those in ICU and 568 deaths. The cumulative confirmed cases graph for Wisconsin continues to rise at a slightly increasing rate as of 5-29-2020. This concave-up graph is slightly trending away from a future plateau. A future inflection point when the graph turns concave-down will indicate trending towards the future plateau. (USA Today Network – Wisconsin, 2020, retrieved from https://projects.jsonline.com/topics/coronavirus/tracking/covid-19-cases-testing-and-deaths-in-wisconsin.html). This includes graphs below:
Computer models have been developed to estimate the timing of surges in clinical demand to inform projected staffing demands and to project when a facility’s capacity would be saturated. One such computer model, developed by the University of Pennsylvania, (CHIME) COVID-19 Hospital Impact Model calculated the following best-case and worse-case scenarios results, considering COVID-19 patients only, for a three-facility healthcare system in their region:
Initial conditions across three system facilities:
Total hospital beds: 1,045
ICU beds: 253
Total demand for hospital beds: 3,131
Demand for ICU beds: 338
Ventilators required: 118
Days until demand exceeds capacity: 53
Total demand for hospital beds: 12,550
Demand for ICU beds: 6,608
Ventilators required: 599
Days until demand exceed capacity: 31
Secondary outcomes derived from this model:
Number of new admissions each day
Number of days until peak demand
Number of days that when current capacity will be exceeded
Immediately, one can see from these results that there is a wide range between best and worse-case scenarios. Also, even in the best-case, the capacity of total beds would be exceeded by the demand by a factor of three. In the worse-case scenario, the capacity of total beds would be exceeded by the demand by a factor of twelve. Even a system with a decade long history of a large percentage of empty beds, may find themselves with pandemic-induced strains on capacity.
EUA is presenting this example as the type of data outputs that would be valuable during architectural programming of immediate facility adaptions in response to a pandemic surge. We are not endorsing the accuracy of any particular model. The CHIME model is limited to short term forecasting, applicable during the period prior to a region’s peak infections. It is available online for free public use with a tutorial (Penn Medicine, Predictive Healthcare, 2020, retrieved from https://penn-chime.phl.io/).
To accommodate immediate bed surge capacity, Wisconsin Department of Health Services (DHS) has advised that the hospital shall conduct a life safety code evaluation based on the NFPA 101 2012 edition of the Life Safety Code and DHS 124 subchapter V. Where the contemplated alteration / expansion is not anticipated to substantially comply, hospitals should submit an interim life safety plan setting forth how the proposed expansion will safeguard patients. This relaxing of requirements also makes the pass / fail criteria less defined. When pass / fail criteria are not well-defined, then the Authority Having Jurisdiction (AHJ) is freer to interpret whether a proposed solution is adequate per their judgement call. The result is less predictability.
Current strategies for patient rooms include:
- Physical distancing
- Isolating beds
- Protocols on surface infection
- Staff and patient separation
- Limiting the number of staff providing care for COVID-19 patients
- Infectious-disease areas sealed off and entered through vestibules
- Where necessary to meet surge capacity, double up patients in rooms designed for one patient. In semi-private patient rooms, only patients with the same respiratory pathogen may be housed in the same room.
- Curtains between patients in shared areas
- Place a patient with known or suspected COVID-19 in a single-person room with a closed door and a dedicated bathroom.
- Negative pressure isolation room is not required by the CDC.
- Consider zoning a department of units to serve patients with known / suspected COVID-19 and another department zoned for other patients.
- Once the patient has been discharged or transferred, healthcare personnel, including environmental services personnel, should refrain from entering the vacated room until sufficient time has elapsed for enough air changes to remove potentially infectious particles. The CDC has published a table indicating the time required for airborne contaminant removal at the following link: https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html#tableb1erminal
After this time has elapsed, the room should undergo appropriate cleaning and surface disinfection before it is returned to routine use.
- Furnishing and accessories:
- Use patient beds and chairs that can withstand disinfection.
- Provide no-touch waste containers with disposable liners in patient rooms and restrooms.
- Provide alcohol-based hand rub and masks in patient rooms.
- Strategies for patient room wings:
- PPE access, storage, distribution and recycling systems.
- All possible measures should be taken to ensure that stairs and elevators in vertical hospitals stay uncontaminated, as they connect many different zones.
- Orient healthcare workers within rapidly changing environments with simple visual aids clearly conveying risk zones.
- Work to make invisible risks more visible.
- Tape, signage or paint can be used to designate these different risk areas and thresholds.
- Add clearly marked donning and doffing areas at major entrances to the unit.
- Utilize access control systems to restrict access to infectious zones to non-staff as the zones are added.
For many hospitals, an early goal was to fit out as many rooms as possible to Airborne Infection Isolation (AII) standards, a time-consuming and involved process. Using negative-pressure ventilation and exhaust that is not recirculated, AII rooms prevent people nearby from being exposed to the airborne virus. But as updated guidance emerged from the U.S. Centers for Disease Control that the virus generally does not hang in air (rather, it clings to larger droplets that quickly precipitate), centers shifted to reserve AII rooms for only the most serious COVID-19 patients, whose treatment produces high quantities of virus-carrying vapor.
- Use air-handling systems (with appropriate directionality, filtration, exchange rate, etc.) that are installed and properly maintained.
- Air-changes: 12 air changes per hour total, with a minimum of 2 air-changes per hour of outside air for an AII room, or 6 air changes per hour total, with a minimum of 2 air-changes per hour of outside air for patient rooms.
- Filtration: Consider adding HEPA-filtered recirculation units in patient rooms to increase air change rates and improve airborne contaminate removal. The current minimum filtration levels for all inpatient care and support areas are the use of MERV 7(30%) pre filters with MERV 14(90-95%) final filters. For more on Filtration: See also Question 9.
- Increase outside air to spaces where infections exist or are known to have occurred:
- Ventilation rates should be increased and maintained 24/7 especially in buildings where known infections exist or are known to have occurred.
- The minimum ventilation rates should at least meet the requirements of ASHRAE-170, Ventilation of Health Care Facilities.
- The maximum amount of outside air can be as high as 100% depending on outdoor air conditions (temperature, humidity, pollution content), indoor conditions trying to be maintained (temperature and humidity), capacity of the HVAC system to condition (filter, heat, cool and dehumidify) the outside air or outside air / return air mixture to conditions that will maintain the desired indoor conditions.
- Applying a combination of increased filter efficiency and increased ventilation rates may be the best way to achieve better indoor air quality and help dilute COVID-19 or other infectious aerosol concentrations indoors (ASHRAE COVID-19 Technical Resources, Q8, retrieved from https://www.ashrae.org/technical-resources/healthcare-faq).
- Normal operating temperature set points should be maintained based on the existing licensing requirements for the space use and occupancy. The most unfavorable survival for micro-organisms when the RH is between 40% - 60%. (Mousavi E, et al, 2019, retrieved from https://www.ashrae.org/file%20library/technical%20resources/COVID-19/ashrae-d-co-rp3.pdf).
The following approaches came from referenced webinar (Vernon W et al, 2020, retrieved from https://event.on24.com/eventRegistration/EventLobbyServlet?target=reg20.jsp&referrer=&eventid=2291743&sessionid=1&key=53BC382D9764B6D2B69B45F862CFC879®Tag=&sourcepage=register).
- Approach 1: The COVID-19 patients were isolated in an isolation ward.
- A HEPA-filtered scrubber was placed at the far-end of the wall to exhaust outside. The 25-feet minimum distance between intake (or other operable openings) from the exhaust of the scrubber had to be maintained.
- The nurse station was placed under positive pressure and located just outside of boundary of the ward. This zoning, along with cameras in each patient room, conserved PPE as well as the donning and doffing time.
- Approach 2: The interim solution was to convert the Post-Anesthesia Care Unit (PACU) to an isolation ward for COVID-19 patients.
- Elective surgeries were cancelled, so this PACU was available.
- The ward was placed under negative pressure.
- Originally, there were three entries into the PACU. During the conversion, two entries were converted into emergency exits only. At the remaining entrance, an air-lock vestibule was added to serve as an anteroom. Hand washing was available directly from the anteroom.
- The private isolation room was used for donning and doffing of PPE.
- Electrical loads will need to be re-evaluated during a pandemic surge. Standard practice has been to require more outlets as time goes on, but the equipment loads per receptacle has also been reduced with time. During a pandemic surge, the outlets are more likely to be used for high-draw equipment such as ventilators.
- One major shift was the focus from individual patient care to unit care. Here enforcing proper infection control protocols in hallways and key thresholds, like entries into units, may be as important as in patient rooms.
Listed below are several options for converting normal patient rooms into negative pressure rooms, or patient wards for isolating COVID-19 patients. Consultation with a mechanical engineer familiar with the design and operation of air systems within the built healthcare environment is recommended, as mechanical system types and capabilities can vary greatly by facility and may limit the possible solutions to meet the facilities goals for isolation.
- Contact a construction manager to use air machines and construct temporary walls to create HEPA filtered negative pressure vestibules outside of patient rooms.
- Block off existing return grille in patient room and install portable negative pressure window units that exhaust room air directly outside after HEPA filtering. Careful consideration needs to be taken if converting multiple patient rooms, as the additional exhaust and the reduction of return air back to the air handling unit may have an adverse effect on the overall performance of the system.
- Rebalance the HVAC system to make the individual patient rooms and department that is zoned to serve patients with known or suspected COVID-19: under negative pressure. Care must be taken to maintain the positive pressure relationship of Clean Linen, Clean Workroom, Clean Holding and other rooms requiring positive pressure.
- Ensure adjacent spaces are protected from cross-contamination. The CDC recommends if a facility is planning on creating an isolated unit for COVID-19 patients, that the air handling system be dedicated to that specific area to prevent any possible cross-contamination of adjacent areas.
- Locate additional exhaust near patient’s head, if possible. (For more options and details about this approach, see also b & c at the end of the answer to question 13).
Option 3: Depending on the capabilities of the air handling unit serving the patient care area and the outdoor weather conditions, running the air handling unit on 100% outdoor air may also be a viable option. In this scenario, all air supplied by the air handling system is exhausted to the outdoors, rather than mixed with some outdoor ventilation air and recirculated to the space.
Option 4: If operating the air handling unit on 100% outdoor air is not viable, the replacement of the MERV 14 final filters at the air handling unit with HEPA filters could be explored. Care needs to be taken with this approach, as there is a significant increase in the air pressure drop across the more efficient HEPA filters that could impact overall airflow of the air handling system. ASHRAE-170 does allow air from AII rooms to be recirculated if it first passes through a MERV 17 or higher HEPA filter.
In areas with confirmed or potential COVID-19 patients, the healthcare facility may deem it desirable to increase the filtration rate for the HVAC systems serving those areas. The system filters should be rated for the maximum filter efficiency available while not adding additional restriction in the HVAC system to cause reductions in system airflow to the point that the system can no longer maintain indoor temperature and humidity set points or desired room pressure relationships. ASHRAE-170 does allow air from AII rooms to be recirculated if it first passes through MERV 17 or higher HEPA filter.
- The current minimum filtration levels for all inpatient care and support areas are the use of MERV 7(30%) pre filters with MERV 14 (90-95%) final filters.
- Specific areas that may benefit from HEPA filtration:
- Isolation wards
- Temporary vestibules
- COVID-19 positive patient rooms
(ASHRAE COVID-19 Technical Resources, Q5, retrieved from https://www.ashrae.org/technical-resources/healthcare-faq).
Temporary anterooms or vestibules with HEPA filtration may be useful for containment at the following locations:
- Entry to COVID-19 patient wards
- At the entry to COVID-19 patient room
- For utilizing an operating room for a COVID-19 patient
Several facilities have patient rooms that have not been utilized for over a decade. In preparation to use these rooms to address potential pandemic surge, the specific requirements for readying medical gas systems require some definition.
- Chad Wetzel, plumbing engineer with RTM’s Milwaukee office confirmed that there is no requirement to “upgrade” an entire med gas system that has been inoperable for some period.
- There is a requirement for maintaining the system, but that is done by replacing the O-rings and any outlets as required before bringing patients into the space. Through the certification process, cleaning and purging the system with nitrogen to check for impurities in the piping, would be done only from the zone valve box to the outlets. Following any preventative maintenance and a successful certification, the system can be ready for patient use.
- The only caveat was a statement in NFPA 99 that mentioned a system component must be replaced or upgraded if it poses a safety risk to patients that has been realized in a newer edition of the code.
The CDC advises to reserve Airborne Infection Isolation (AII) rooms for patients undergoing aerosol generating procedures.
- AII rooms are single-patient rooms at negative pressure relative to the surrounding areas. For rooms constructed before approximately 1995, AII rooms were required to maintain a minimum of 6 air changes per hours. For rooms constructed after this time, whether new construction or renovation, require a minimum of 12 air changes per hour.
- Air from these rooms must be exhausted directly to the outside or be filtered through a high-efficiency particulate air (HEPA) filter directly before recirculation to the system. HEPA, is a designation used to describe filters that are able to trap 99.97 percent of particles that are 0.3 microns. In addition to filter efficiency, diffusion is the filtration method where smaller particles move in a zigzag or random path and stick to the filter fiber. Diffusion occurs because of the Brownian motion where gas particles constantly collide with each other moving in a random motion. Diffusion primarily happens to particles smaller than 0.1 microns in size and with slower air flow. Nearly 100 percent of these tinier particles stick to the filter fiber for this reason (Conway Mega, 2020, retrieved from https://cowaymega.com/blogs/blog/what-is-a-hepa-filter).
- Room doors should be kept closed except when entering or leaving the room and entry and exit should be minimized.
- Facilities are required to monitor and document the proper negative-pressure function of these rooms while they are being used to isolate an infectious patient. Many facilities opt to install a room pressure monitor to continually monitor and record the room pressure utilizing the Building Automation System. The room pressure monitors also notify nursing and maintenance staff when the AII room is not maintain adequate negative pressure.
- Prioritize respirators for aerosol-generating procedures.
Prefabricated AII rooms allow interiors of existing buildings to be manufactured quickly and in controlled factories with extreme precision. Components and assemblies are evaluated and approved by third-party testing and listing agencies such as International Code Council Evaluation Services (ICC-ES). The ICC-ES Listing Program offers a fast and cost-effective way for manufacturers of building products covered by existing consensus standards to show their product compliance with applicable standards referenced in the building codes. Common characteristics of prefabricated AII rooms include:
- Fully pre-assembled with minimal work on site.
- Prewired utilities.
- Shower, hands-free wash station and toilet.
- Clinical hand wash station with hands-free operation.
- Self-closing, interlock doors.
- Easily cleaned chemical resistant walls, doors and windows.
- No recirculating air, HEPA filtered exhaust, supply air ducts independent from building HVAC system. Notification upon loss of differential pressure.
Prefabricating modular structures, such as the one in the illustration below, can be delivered on a standard truck trailer, with two finished patient rooms and a bathroom, along with medical and HVAC infrastructure meeting the negative-pressure standards for AII rooms.
- Units can be assembled in various configurations once onsite.
- A few of several manufacturers available include:
- Metcart Cleanrooms
Retrieved from: https://www.isorooms.com/airborne-infection-isolation-rooms.html
Other strategies include:
- Adapting an existing patient bed wing to private rooms with negative air pressure or with individual ductless units, which do not circulate through ductwork into a central HVAC system. Either way, the selected bed wing has capabilities to be separated from the general HVAC system of other floors or zones.
- Determine admission points that bypass the general public and have the most direct access to the selected bed wing.
- Select bed wing that is apart from other patient populations.
- FGI requires AII rooms to have self-closing doors and an air-tight enclosure.
- Consider the following to address infectious aerosols in the design and operation of healthcare buildings: Capture expiratory aerosols with headwall, tent or snorkel exhaust options with HEPA grade filtration located at near the patient’s head and supply air near the room door. (ASHRAE Position Document on Infectious Aerosols, 2020, retrieved from https://www.ashrae.org/file%20library/about/position%20documents/pd_infectiousaerosols_2020.pdf).
- A novel retractable canopy for filtered exhaust, located above the patient’s head, was found to be the most effective configuration for removing contaminants before they can contact healthcare workers. This extraction of contaminants immediately as the patient coughs improves protection of healthcare workers from both long-range and short-range infectious bioaerosols (Thatiparti D et al, 2009, retrieved from https://www.ashrae.org/file%20library/technical%20resources/COVID-19/lb-17-c005.pdf).
Provide single bed patient room with private bathroom for each individual ICU/CCU patient. These rooms are larger to provide additional spaces for various care activities. Per 2018 FGI Guidelines, the minimum requirements for a Medical/Surgical patient room is 120 sq ft of clear floor space. By comparison, the minimum requirements for an ICU/CCU patient room is 200 sq ft of clear floor space. This additional space accommodates the following:
- Patients within ICU/CCU require life support and ventilators.
- Other specialized monitoring and equipment such as intravenous pumps, medication cart, crash cart, patient handling lifts, etc.
- Staff assistance is accommodated all along the patient path from the bed to the bathroom.
ICU/CCU have increased medical gases and power capacity requirements. Sound masking may assist to create a quiet environment.
Under non-pandemic conditions:
- ICU/CCU rooms are under direct observation from the nurse station. Here, by “direct” we mean a view through glass doors or sidelights and not “indirect” observation via video camera and remote monitoring. If existing sliding doors are off of a suite passage in lieu of a public corridor, they are most likely not airtight.
Under pandemic conditions:
- ICU/CCU rooms can be under “indirect” observation via video camera and remote monitoring.
- This virtual observation has the following benefits:
- Minimizes staff exposure to COVID-19 patients
- Enables more frequent patient interactions
- Conserves PPE (An iPad permits a patient to see the facial expressions of care givers without a mask. Nurses can use the devices to check on patients without donning PPE.)
- Supplements staffing to address shortages
- Family members may have audio and visual contact with the patient.
- Not having to wake up patient at 2:00 am to read vitals, allows better rest assisting with faster recovery.
- One strategy for patient monitoring is to have a nurse, donned with PPE, hold a camera and visit one patient at a time while the physician is watching a remote monitor. As the nurse moves on to the next patient, she changes gloves but keeps gowns and goggles on. This complies with standards and saves PPE.
Staff Sleeping Rooms
Sleeping rooms for clinical and support staff are another programmatic element to consider during pandemic surge conditions. An existing staff sleeping room can comply with the code requirements enforced at the time of construction. When a room of another function is being considered for conversion, then consider the following:
A sleeping room would have to comply with the Life Safety Code (LSC) provisions for a hotel / dormitory occupancy. Since it is incidental to the predominant occupancy of the facility (that being healthcare occupancy) LSC allows for a mixed occupancy and separation between the occupancies is not required provided the most restrictive requirements of the occupancies have been followed.
A single-station smoke alarm and a closer and lock on the door to the corridor for the sleeping room are required because the most restrictive requirement of the occupancies involved must be met, and these items are required in a hotel / dormitory occupancy. These should include basic amenities such as a bed and clean linens, lighting and temperature control, functioning toilets and sinks, showers with hot water, locking door, a desk and a chair, a computer and regular housekeeping.
A toilet, sink and shower are required by 2014 FGI, 2.2-22.214.171.124 (4).
The 2015 International Building Code (IBC) states that buildings must have an outside window in every sleeping room, and for any building constructed 60 days past the publication date, the sill height must not exceed 36 inches above the floor. Exceptions include rooms intended for occupancy for less than 24 hours.
Non-patient sleeping rooms in the healthcare occupancy do require single-station smoke alarms, such as the battery powered type found in residential homes. They are not required to be inter-connected with other smoke alarms or the building fire alarm system. In the case of on-call sleeping rooms, LSC does require single-station smoke alarms such as a simple 9-volt residential style smoke alarm installed no more than 12 inches below the ceiling. Put these devices on your PM schedule to have the batteries replaced once per year.
Procedure / Operating Rooms
For COVID-19 positive patients, the CDC recommendation is to ideally perform all Aerosol Generating Procedures in Airborne Infection Isolation (AII) rooms which are negative pressure.
This recommendation leads individuals to consider performing surgeries and other procedures that are normally performed in positive pressure rooms in negative pressure rooms due to the possibility of aspiration generation. Commonly performed medical procedures that are considered Aerosol Generating Procedures:
- Open suctioning of airways
- Sputum induction
- Cardiopulmonary resuscitation
- Endotracheal intubation and extubation
- Non-invasive ventilation (e.g., BiPAP, CPAP)
- Manual ventilation
American Society of Healthcare Engineers (ASHE) recommends that health care organizations perform surgeries and other procedures on COVID-19 positive patients following the same guidelines for active tuberculosis patients:
- Only medically necessary surgeries or procedures should be scheduled and performed “after hours” or when there are no other non-COVID-19 positive patients within the suite.
- Develop a dedicated COVID-19 operating room (OR) and procedure room.
- Minimize the amount of equipment and supplies in room is one proven action to prevent transmission.
- Minimize the number of people in the OR or procedure room to reduce exposures. All staff involved should wear N95 respirators.
- All doors to the OR or procedure room should be kept closed as much as possible.
- Assigning a runner outside of the room who will retrieve medications, instrumentation and other supplies to minimize opening of doors should be considered.
- If possible, intubation and extubation should be performed in an Airborne Infection Isolation room.
- Terminal cleaning should be performed only after the necessary number of air changes has occurred to remove potentially infections particles.
- If it is determined to provide negative pressure for these clinical services, leaving the room ventilation in a positive pressure status and utilizing a negative pressure anteroom with separate entrance between operating or procedure room and main hallway is recommended. This anteroom can also be used for donning and doffing PPE and the placing of supplies that are needed after case begins (retrieved from https://www.ashe.org/ashe-issues-recommendation-or-use-during-COVID-19).
- Negative pressure rooms for highly infectious patients are recommended. If elective surgeries have been halted, operating rooms can be repurposed as negative pressure rooms. During the COVID-19 pandemic, CDC recommends that facilities:
- Postpone elective surgery and procedures.
- Minimize the use of procedures or techniques that might produce infectious aerosols when feasible.
- If surgery or procedures cannot be postponed, healthcare personnel caring for patients with suspected or confirmed COVID-19 should adhere to all recommended infection prevention and control practices for COVID-19. This includes using all recommended PPE: an N95 or higher-level respirator (or facemask if respirators are not available), eye protection, gloves and a gown. As part of routine practice, healthcare personnel should also be using appropriate engineering controls for source control (e.g. smoke evacuation devices).
The following approaches came from referenced webinar (Vernon W et al, 2020, retrieved from https://event.on24.com/eventRegistration/EventLobbyServlet?target=reg20.jsp&referrer=&eventid=2291743&sessionid=1&key=53BC382D9764B6D2B69B45F862CFC879®Tag=&sourcepage=register).
- Physical separation of aerosol generating procedures.
- Dilution reduces risk. Filtration is an effective use of dilution.
- Controlling direction of airflow can improve containment and reduce risk.
- Two possible strategies for preparing an OR for COVID-19 patients:
- Negative Pressure.
- Positive Pressure (and capture air).
Medxcel selected the Positive Pressure option to create two ORs designated for COVID-19 patients.
- OR pressure room monitors were required.
- In each OR one of the two low returns were blocked off and replaced with a HEPA-filtered air scrubber.
- This option involved creating an 8-feet wide anteroom within a Section of the corridor that accessed both rooms.
- A HEPA-filtered scrubber was added to the anteroom above each corridor entry to the anteroom.
- The FGI does not require anterooms, but with the selected strategy of positive pressure ORs, the engineer felt these to be a required integral component of capturing infection. If the ORs were radically negative, then they would have not been required.
- The doors were sized for beds, not gurneys, since moving patients in beds used much less PPE.
- An HVAC control system was needed to detect if the pressure differential should ever go out of tolerance and to remedy these conditions remotely.
- The air balancing of the entire HVAC system serving the OR’s needed to be checked.
- If the cause of the reduction in production is a shortage of PPE supplies, reference USP and your state’s Pharmacy Board for potential modifications to regulations regarding PPE usage, operational changes and emergency rules.
- Compounding Hand Sanitizer:
- Hand sanitizer production wouldn’t necessarily need an ISO level cleanroom, so there are likely better places in the hospital to produce; such as a fume hood (like one possibly located in a blood bank or shared diagnostic lab) would be better than a biosafety cabinet.
- Laminar flow workstations, CAI and CACI gloveboxes should not be used as they do not remove fumes.
- 100% exhausted hoods would be ideal, no recirculation within the hood (only Type B2, no Type A or B1 hoods).
- Both Baker and Nu-Aire user manuals indicate that if B2 hoods are listed for UL 1805 they can handle flammables and volatiles.
- Fumes / gases are not stopped by HEPA filters, however there may be risk of saturated particles becoming concentrated in a filter.
- If a BSC must be used, either the HEPA exhaust filter would need to be removed prior to starting or disposed of afterward.
- Spill kits and eyewashes would need to be in place to deal with any emergencies.
- Safe storage for raw materials would need to be considered.
- NFPA 45 has limits on the maximum volume of flammable liquids allowed in a lab.
- See page 9 of the following document for more considerations (WHO, 2020, retrieved from https://www.who.int/gpsc/5may/Guide_to_Local_Production.pdf).
- See USP website for additional resources: https://go.usp.org/hand_sanitizer
The Food and Drug Administration (FDA) and the Drug Enforcement Agency (DEA) have temporarily altered some rules related to pharmacy practices to both address potential drug shortages the pandemic may cause as well as shortages of equipment pharmacists need to compound sterile drugs.
- The FDA is temporarily allowing small compounding pharmacies to supply hospitals that can’t buy drugs from their usual manufacturers.
- The FDA is temporarily relaxing drug compounding rules in response to a shortage of drugs needed to put COVID-19 patients on ventilators. For as long as the pandemic lasts, the agency said it will not act against compounding pharmacies that make a drug that is a copy of an approved drug, use bulk ingredients not on an approved list or fail to meet good manufacturing requirements for stability.
- DEA lifted three restrictions on hospitals and pharmacies during the COVID-19 pandemic.
- The first exception allows DEA-registered hospitals and clinics to handle controlled substances at their satellite locations if certain conditions are met.
- The second exception allows narcotic treatment programs to accept deliveries of narcotics without having to provide a signature at the time of delivery, so people don't have to come into contact as an effort to prevent the spread of COVID-19.
- The third exception allows DEA-registered dispensers, including hospitals, pharmacies and physicians, to distribute controlled substances beyond the five percent limit.
- The FDA will allow pharmacists to use nonstandard personal protective equipment (PPE) to compound drugs if standard protective gear can't be obtained by pharmacies during the COVID-19 pandemic.
- The FDA released four updated rules hospital pharmacies must follow under the federal Food, Drug and Cosmetic Act when it comes to compounding drugs to address problems that may arise during the COVID-19 pandemic.
- The DEA has increased production limits for some controlled substances that have seen demand spike due to the COVID-19 pandemic (Anderson, M, 2020, retrieved from https://www.beckershospitalreview.com/pharmacy/6-federal-pharmacy-policy-changes-in-response-to-the-covid-19-pandemic.html).
Flows Between Rooms
Many facilities do not have separate spaces to receive, break down and disinfect supplies properly. Hospitals and surgery centers use this type of zoning, which can be scaled appropriately for all facilities as needed during emergent situations. Control vendor entry and flow of deliveries to ensure that they are properly cleaned.
Strategies to separate patient flows include:
- Limit transport of patient outside of the room to medically essential purposes.
- Perform procedures / tests in the patient’s room. Consider providing portable x-ray equipment in patient cohort areas to reduce the need for patient transport.
- Use dedicated medical equipment when caring for patients with known or suspected COVID-19. All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer’s instructions and facility policies.
Some specific strategies based on type of flows:
- Vendors have identified healthcare facilities as priority customers in the event of a disaster.
- Non-perishable stocks shall be increased by at least appropriate percentage; therefore, offsite storage may be required.
- Adapt menus for convenience and ready to use items. Include disposable products for serving when appropriate.
- Use single-use, disposable cleaning supplies.
- Additional waste receptacles may be required, as well as additional transport services from medical waste vendors.
- Cleaning products will be assessed and revised based on products recommended for use during the COVID-19 pandemic.
- Depending on the usage of linen per patient per day, additional quantities of supplies may be required, as well as additional deliveries.
- Specialty items will continue to be laundered by the facility.
During the pandemic, it is expected that the quantity of deaths will increase and may require additional cold storage space to accommodate additional capacity. External cold storage units may be necessary for storage until remains can be processed by funeral directors. Funeral homes will be contacted to transport remains as soon as possible.
Aerosol generating procedure (AGP): Procedures that are likely to induce coughing. Procedures that are believed to generate aerosols and droplets as a source of respiratory pathogens include positive pressure ventilation (bi-level positive airway pressure (BiPAP) and continuous positive airway pressure (CPAP)), endotracheal intubation, airway suction, high-frequency oscillatory ventilation, tracheostomy, chest physiotherapy, nebulizer treatment, sputum induction and bronchoscopy. AGPs should ideally take place in an airborne infection isolation room (AII) room. Source CDC.
Bronchoscopy: A procedure that uses a bronchoscope to examine the inside of the trachea, bronchi (air passages that lead to the lungs) and lungs. A bronchoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue to be checked under a microscope for signs of disease. The bronchoscope is inserted through the nose or mouth.
Extubation: The removal of a tube previously inserted into a patient's body, especially that of an artificial ventilation tube from the trachea.
Infectious aerosol: A system of liquid or solid particles uniformly distributed in a finely divided state through a gas, usually air. (They are small and buoyant enough to behave much like a gas, yet they can be filtered out of the gas.) Source ASHRAE Position Document on Infectious Aerosols.
Intubation: The insertion of a tube into a patient's body, especially that of an artificial ventilation tube into the trachea.
Sputum induction: A procedure used for patients who have trouble producing sputum spontaneously. The patient inhales nebulized hypertonic saline solution, which liquefies airway secretions, promotes coughing and allows expectoration of respiratory secretions.
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- Rabinowitz, B. (2020) Tips for keeping your practice safe and mitigating the spread of COVID-19. Medical Economics. Retrieved from https://www.medicaleconomics.com/news/tips-keeping-your-practice-safe-and-mitigating-spread-covid-19
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- American Academy of Family Physicians (AAFP). (2020) Checklist to Prepare Physician Offices for COVID-19. Retrieved from https://www.aafp.org/dam/AAFP/documents/patient_care/public_health/COVID-19%20Office%20Prep%20Checklist.pdf
- CDC. (2020) Preparedness Tools for Healthcare Professionals and Facilities Responding to Coronavirus (COVID-19). Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/preparedness-checklists.html
- CDC. (2020) Get Your Clinic Ready for Coronavirus Disease 2019 (COVID-19). Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinic-preparedness.html
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- Vernon W, Crabb Jim, Skelton D. and C Roberts. (2020) Engineering “Must Haves” and “Nice to Haves” in Managing the Patient Surge Crisis While Mitigating Cross Infection. Retrieved from https://event.on24.com/eventRegistration/EventLobbyServlet?target=reg20.jsp&referrer=&eventid=2291743&sessionid=1&key=53BC382D9764B6D2B69B45F862CFC879®Tag=&sourcepage=register
- WHO. (2020). Guide to Local Production: WHO-recommended Handrub Formulations. Retrieved from https://www.who.int/gpsc/5may/Guide_to_Local_Production.pdf
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- ASHRAE, Environmental Health Committee. (2020) Emerging Issue Brief: Pandemic COVID-19 and Airborne Transmission. Retrieved from https://www.ashrae.org/file%20library/technical%20resources/COVID-19/eiband-airbornetransmission.pdf
- ASHRAE, Position Document on Infectious Aerosols (2020) Retrieved from https://www.ashrae.org/file%20library/about/position%20documents/pd_infectiousaerosols_2020.pdf
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- Marty Petroviak, RA, CSS, LEED AP | EUA
- Paul Stefanski, AIA, EDAC, LEED AP | EUA
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- Ian McAteer, RA, NCARB | EUA
- Nick Gates, RA, NCARB | EUA
- Martin Herrick, PE, HFDP | RTM Engineering
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