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Introduction

This document will assist local health districts (LHDs) to:

  • Establish a process to review all possible clinical care environments within their hospitals, to enable surge capacity in response to the management of COVID-19 patients.
  • Facility and engineering advice needed to make the space ready for the care of patients with COVID-19 requiring a range of clinical care including intubation and mechanical ventilation. These clinical spaces may include existing or vacated inpatient units (IPU), recovery, operating theatres and day medical spaces

Appendix A provides further specific detail for reinstating clinical spaces that are currently not in use for patient care.

Appendix B provides further specific detail for adapting clinical spaces that are currently in use for patient care.

While the Australasian Health Facility Guidelines (AusHFG) would typically be used to inform reconfiguration, the requirement to enhance the number of ICU-ready spaces means that information in this Guideline will be used instead. 

Health Infrastructure is available to support LHDs with the interpretation of this document and other related technical details. 

The contact is Rochelle McKnight - Rochelle.Mcknight@health.nsw.gov.au or  0416 009 629. 

Identifying a location

A​ desk-top planning exercise should be conducted to identify suitable space within existing hospitals, this should occur with reference to the NSW Health Influenza Pandemic Plan and local LHD Pandemic Plans and the facility and engineering advice provided in this document.

This desk-top exercise may:

  • Identify space that is either vacated or currently used for non-clinical purposes (e.g. IPU used as office space) that may have retained the power, data and medical gases needed to support patient care during a surge response. 
  • Consider reorganising clinical care across the hospital to ensure adequate and appropriate space is zoned for the cohorting and management of patients with COVID-19. In some cases, it may be more appropriate to manage COVID-19 patients in an IPU and move general patients to recovery areas. While a range of clinical bed spaces may be ICU adaptable, spaces such as IPU might routinely be used for the ICU type 2 patient. This document will address the clinical, facility and engineering requirements needed to equip each bed space. 

Where possible, a designated self-contained area or zone of the hospital should be used for the management of patients with COVID-19. Items for consideration: 

  • Controlled access and a dedicated reception point or an access control system with video-intercom;
  • Segregation by closed doors from areas within the IPU that are not being used for the care of patients with COVID 19; 
  • High traffic areas should consider touchless entry automatic doors;
  • Wall and floor signage displaying warning of the segregated area to control entry;
  • Not be used as a thoroughfare by other patients, visitors or staff, including the transfer of patients and staff and visitors entering and exiting the building;
  • Have space available within the designated clinical area to don/ doff, store PPE and waste as detailed in the table below. 

Other considerations

Issu​e​​​​​ Consideration
​Bed space type

Where possible, patients should be managed in a single room. As patient numbers increase, cohorting of confirmed patients in shared rooms will be required. Special environmental controls, such as negative pressure isolation rooms, are not necessary to prevent the transmission of COVID-19 as the pathogen is spread via contact and droplet. The need for negative pressure controls are recommended for aerosol generating procedures (AGPs) and if a negative pressure room is not available a single room with the door closed is sufficient. Refer to Sections 6 and 7 for further detail.

Change rooms (on arrival/ departure to/from hospital)

A room should be identified for staff to change into their uniforms or scrubs as provided by the Health Organisation (HO) (likely scrubs) on arrival and before they enter the IPU. This may be centralised change areas or a local room, outside of the IPU converted for the purpose. Access to showers is preferred if possible, providing the staff member the option to shower and change prior to returning home to their family. Only required if this is the agreed system of work as the use of scrubs is not universal. Locker space will be needed to secure staff property such as clothes and other personal items.

Utility areas

All IPU should have space available to manage clean (i.e. linen, PPE, food trolleys and sterile consumables) and dirty materials (i.e. dirty utility, disposal rooms) and flows. Waste, including discarded PPE, and linen should be held in a dedicated space within the IPU until collected by environmental services staff.

Entry to clinical zone

Area for donning of PPE should be identified based on the model of care. For high risk areas, PPE may be required on entry to the unit and space should be identified outside rooms for donning and doffing. This zone may need to be marked out and /or signage displayed to identify PPE entry zone. 

 Staff should have access to ABHR, a nearby handwash basin and a supply of PPE that is stored correctly so as not to become contaminated. Where negative pressure rooms are used, these activities can occur in the anteroom (where available) which will be zoned to separate activities from clean entry and donning to contaminated doffing exit. .

Hand hygiene

Access to a handwash basin will be available in all clinical areas of the hospital. This will range from a dedicated basin in each IPU bedroom to shared access in areas such as recovery. Where an operating theatre is used, the scrub sink can be accessed. ABHR to be supplied at each bed space easily accessible for staff to use as required.

Waste bins

No touch bins should be supplied in clinical spaces (e.g. foot operated).

Storage

Any storage /shelving in patient bed spaces must be kept to a minimum. Where provided the storage system should be easy to clean and /or easily moved to ensure thorough cleaning can be undertaken.

​​​​​
Where ICU type care is identified to be delivered, the following items are to be acknowledged:
  • A typical single bedroom and 2 bedroom will have the clearances needed to manage these patients. 
  • Dedicated ICU and operating theatre spaces will be an adequate size. 
  • Recovery bays may be undersized for longer term ICU-type care (current AusHFG dimensions are 2800mm x 3300mm) but the curtain arrangement as well as circulating corridor system at the base of each bedspace will provide the space needed when required. 
  • Should a temporary ICU be built using a ‘quick-build’ solution, then the ideal minimum sized room or bay will be 3600mm wide and 4200mm long.

Room fabric

The room fabric in an ICU bedroom is broadly consistent with the level of fit-out provided in a range of clinical spaces. The room fabric includes wall, ceiling, floor/ skirting, door and window finishes. The only differences may be that:
  • ceiling tiles may be used in an IPU, recovery or short stay unit while a fixed plasterboard ceiling is typically provided in an ICU bedroom and operating theatre
  • a Type B basin is provided in an IPU bedroom, recovery (stage 2) and short stay units while a Type A basin is provided in an ICU bedroom and recovery (stage 1)
  • other care spaces may have roller blinds as the window covering while an ICU will instead use integral venetians
  • an IPU bed space does not have a ceiling mounted examination light, a portable solution can be used as needed.
It is recommended that no other changes to this basic room fabric is undertaken.

Medical services

A modern ICU will use pendants. These are unlikely to be provided in other clinical environments where they do not already exist. The following table describes the minimal services required to adapt any clinical space with a basic range of services to an ICU adaptable space. 

​​Service ​Typical bed space ​ICU adaptable spaces ​​Other comments
​Nurse call ​Yes ​Yes ​Modified systems in operating theatres.​
​Body/cardiac protection ​Body protection ​Body protection ​Refer to Section 8 for further details. 
​Oxygen ​1 ​2 ​Where a second outlet is required, a large oxygen cylinder will be used. Alternatively, a double connection adaptor could be used in place of cylinders subject to adequate performance. 
​Medical air ​1 ​1
​Suction ​1 ​2 ​Where a second outlet is required, a portable unit will be provided. Typically when non-invasive ventilation is used. Alternatively, a double connection adaptor could be used in place of a mobile unit subject to adequate performance.
​Cardiac monitoring ​0 ​Bracked ​May need to be considered where invasive monitoring is required and a portable solution (e.g. trolley) is not feasible. 
​GPO – double, bed ​1 ​1 ​Staff need to prioritise what equipment is powered by emergency outlets. This is to be undertaken using a risk assessment approach to determine priority.
​GPO – single, emergency power​ ​4 ​4 ​As above for 'GPO – double, bed​'
​GPO – single ​4 ​4 ​As above for 'GPO – double, bed​'​
​Data outlet – double ​1 ​1 ​Wireless network may have to be used to support other equipment such as WOWs and monitoring. May be that eMR is replaced with downtime procedures. 
​GPO – UPS ​0 ​0 ​Some equipment such as ventilators, central monitors and infusion pumps have a battery built in. 
​Lighting dimmable ​0 ​0 ​Do without. Room has a range of suitable lighting options. 
​Residual current device ​Yes ​Yes
​Reverse osmosis (RO) station ​0 ​0 ​If renal replacement therapy is needed then it should be managed in a space with an RO station. It is possible to use a portable RO machine so piped RO water is not ​needed. ​
    

Medical equipment

In addition to the services listed above, where ICU type care will be delivered, a typical bedspace may need to be supplemented:
  • A range of beds. A typical electric inpatient bed will be adequate in most cases
  • Workstation on wheels, unless downtime procedures in place
  • Ventilator (if the bed space is being used for this type of care) -
  • Transport ventilator that can be shared
  • Cardiac monitor with HR, IVBP, Sa02, ETCO2 capability (where ventilation is needed)
  • Vital signs machines (where there is no cardiac monitor)
  • Portable examination light
  • Portable oxygen cylinders including adapters
  • Portable suction units 
  • Storage solution (e.g. trolley) for consumables within the room. Mainly an issue for ICU Type 1 bed spaces
  • Linen skip which can be stored in ensuite or nearby
  • No touch waste receptacles (including sharps disposal bin)
  • IV poles, drain/ urine bag holders
  • Access to manual handling equipment such as patient lifters (shared) / hovermats and pumps
  • A range of infusion pumps, syringe pumps and enteral feeding pumps
  • Consideration of a communication system between the single room and staff outside. Portable systems preferred if needed
  • Pressure relieving mattress (as may be required) 

Air conditioning

Clinical requirement underpinning recommendations

Based on current advice from the Clinical Excellence Commission, special environmental controls, such as negative pressure isolation rooms or negative pressure air flows within an entire clinical unit, are not necessary to prevent the transmission of COVID-19 as the pathogen is spread via contact and droplet. The need for negative pressure controls are recommended for aerosol generating procedures but where not available alternative of single room with door closed is sufficient. It is important to note the aerosolisation of droplets does not create airborne spread. This advice is consistent with National and International recommendations.

The use of standard bed spaces

The overwhelming majority of patients with COVID-19 can be managed in standard clinical environments without any change needed to air handling systems. 

Health services should check existing air handling systems to:

  • Assess the existing configuration, air flows, air changes and pressures
  • Ensure the air conditioning and ventilation system is functioning properly
  • Replace existing filters with new for this purpose. Monitor filter pressure drops across filters at weekly intervals to ensure that filters are functioning and replace filters when the pressure drop reaches 80% of maximum allowable limit.

Negative pressure rooms can be used to accommodate patient care requiring AGP. An alternative is the use of a hood as shown in Figure 2.

Figure 2: Hood for AGP



Negative pressure environments

On the basis that there is a need to increase the number of rooms/areas with a negative pressure environment to support the expected increase patient numbers, the following advice should be considered. 

Where a room is built with its own return/ exhaust, adjustments could be made easily, and without significant cost, to generate negative pressure. The majority of hospitals have operating theatres with their own return/ exhaust. All rooms should have a dedicated air handling system, the existing arrangement would have a supply air volume in excess of the return/ exhaust volume to generate a positive environment for the normal functioning of the operating theatre. 

If both supply and return/ exhaust air volumes were adjusted and rebalanced by adjusting the fan speeds/ balancing dampers, the positive pressure can be reversed to a negative pressure environment. This will not be equivalent to a Class N isolation room but will prevent air from this room from flowing outwards. To provide visual indication of pressure differential, a wall mounted differential gauge can be installed on the outside wall of each room that is converted for this purpose (e.g. magna helix guage).

Hospitals with air handling systems serving multiple theatres, should be excluded from this use.

All existing operating theatre systems have terminal HEPA filters in the supply air outlets in the theatre (some older systems may have in-line filters) and these can remain in operation.

Check all exhaust discharge points are in correct and compliant locations in accordance with relevant standards.

While this approach is recommended for single rooms or spaces, should the approach be considered for larger areas which are equipped with dedicated exhaust fan and discharge path, then advice should be obtained by a mechanical engineer, Health Infrastructure can provide recommendations - contact details are in the introduction.  

Refer to the following section for additional considerations relating to ventilation. 

Other engineering and related considerations​

Issu​​e​​​​​ Consideration
Oxygen

All clinical bed spaces are equipped with at least one oxygen outlet. 

Under the expected high demand of every patient being intubated, the local distribution pipework may not support volumes and pressure, resulting in low pressure/flow at the outlets, as the pipework have been designed for normal diversified operation. Test flows in pre commissioning, and as a contingency back-up, additional portable oxygen bottles can be used for a portion of the beds to reduce the load on the distribution pipework and enable all beds to have proper flow.

If oxygen bottles were to be deployed, then a storage area will need to be established, with clear demarcation between full and empty bottles. Its location should facilitate easy delivery of new bottles and removal of empty bottles.

All hospitals of a certain size and scale will be equipped with centralised oxygen supply, the overall consumption may increase thus will result in more frequent delivery and refilling. Most tanks have remote monitoring and automatic ordering system with the suppliers. Check and ensure that this is functioning properly.

Consideration should be given to undertaking a site medical gas performance capability test to determine the maximum infrastructure capacity available. This test may assist to inform the planning and use of supplementary bottle supply and use strategies. This test however should not delay the progress or completion of works. 

Ensure compliance with Australian Standards AS2896-2011 and NSW Health PD_2017_007 Managing the installation, refurbishment and commissioning of medical gas systems​

Suction

All bed spaces are equipped with at least one suction outlet. • Under the expected high demand for ventilation, both the local distribution pipework and the central suction vacuum pumps may struggle to keep up, resulting in low pressure/ flow at the outlets, as the systems have been designed for normal diversified operation. If this was to occur, individual local suction pumps can be used for a number of the beds to reduce the load on the system and enable all beds to have proper flow.

​Medical air

All beds are equipped with at least one medical air outlet. It is expected the system will be able to cope and additional bottled gases will not be needed.

Ventilation

All existing IPU bedrooms are provided with air conditioning with an outside air component complying with regulatory requirements. This is expected to be adequate for intubated patients. With the high number of intubated patients and thus the oxygen used, the oxygen level in the rooms may/will increase. The normal atmospheric background oxygen level is 20.9%, if this was to rise to above 23.5% than it is viewed as oxygen enriched and will pose a higher ignition and fire hazard. It is recommended that portable oxygen sensors are deployed in various rooms for periods of time in each to establish the oxygen level under the desired operation regime (i.e., number of intubated patients in a room), and if necessary review the density of beds to manage the oxygen level.

Electrical power supply

Existing beds are likely to already have a high number or power outlets, some of these are supported by the emergency power system. The number and capacity are both expected to be adequate. For any monitoring or life supporting equipment, it would be recommended that the standby power supported outlets be used. No UPS is available in a typical IPU bed space and this is expected to be adequate.

Body/cardiac protection​

With the exception of ICU (adult, paediatric and neonatal), cardiac theatres, cath labs and CCU beds, cardiac protection is not supplied to other bed spaces (i.e. IPU, short stay unit, recovery or general operating theatres). These spaces are equipped with body protection. The Australian Standard AS/NZS 3003:2018 Electrical installations - Patient areas states that ‘a patient area shall only be wired as a cardiac-protected electrical area if cardiac-type procedures as determined by the responsible organization/ entity are to be undertaken on a regular and routine basis’. It is also only required in ICU bed space where ‘regular thermodilution Swann-Ganz monitoring’ also known as Pulmonary Artery catheter monitoring is conducted (p. 19). As ICU adaptable bed spaces will not be used on a regular and routine basis, the existing body protection system will be deemed as adequate.

​IC&T​ ​Existing beds are likely to be equipped with at least one double data outlet and these are expected to be adequate. For equipment that has wireless capability and communication with a medical centralised reporting or monitoring system, these are expected to be set up already for their normal operation.​
​Fire safety ​All recent hospitals are provided with fire sprinklers, which are above code requirements to provide fire protection for patients. Fire detection and alarm systems are also provided. Consider a review of evacuation procedures if changes in layout have occurred or major change in patient acuity is planned. 
​Room temperature & humidity ​If a bed or a single bedroom was to have a higher than normal number of equipment items in operation, this may lead to a rise in localised room temperature. It is expected the air conditioning system will cope in most cases. In some cases, there may be an increase but it is not expected to become untenable.
Renal replacement therapy ​​It is recommended that any patients that require both intubation and renal replacement therapy (RRT) be treated in ICU or other bed spaces equipped with a RO station. 

Commissioning bed spaces

When delivering new and adapted bed spaces, the operational commissioning of these spaces should be adapted in line with standard operational policies and procedures such as (but not limited to): 

  • Infection prevention and control
  • Work health and safety
  • Environmental services including cleaning, linen and waste
  • Clinical support services such as pathology
  • Supply services
  • Food services
  • Transport (both internal and external)
  • Building services (medical gases, HVAC and electrical supply)

Appendix A – Draft process to follow:

Reinstating clinical spaces that are currently not in use for patient care

For a site identified for recommissioning, the following appendix outlines the suggested process for site auditing, procurement, recommissioning. 

The suggested process steps include:

1. Site/ IPU/ unit is identified as designated surge capacity work

2. Site Audit. Project team including services contractors and trades to audit site and produce return brief on

  • Scope of works required to complete recommissioning in line with the brief and this guide
  • Status/ condition of all infrastructure and plant/ equipment
  • Procurement list
  • Estimated time to completion
  • Cost estimate
  • Minimal changes are expected where possible
3. LHD should undertake a risk assessment regarding the extent of change. This should also consider the requirement for BCA advice. Recommendations from Health Infrastructure can be provided - contact details are in the introduction

4. At time of recommissioning, all trades to produce commissioning records for works in line with Australian Standards

  • Medical gasses
  • Electrical outlets and RCD testing for body certification compliance
  • Communications connectivity (as applicable)
  • Nurse call functionality
  • Mechanical air handling systems
  • Fire protection and detection systems
  • Emergency evacuation operation (EWIS/ SSEIP)
  • Hydrants/ hose reel systems. 

5. Review​ building systems that support the unit to assess:

  • If air handling unit is suitable, review to determine if outside air and associated relief can be increased to achieve increased air changes for excessive oxygen build up if required (where higher than normal oxygen therapy is used such as patient ventilation)
  • For operating theatres that have been rebalanced to provide negative pressure environments, it should be noted that all existing settings of dampers, VSD's etc. should be locally marked and recorded to allow easier reestablishment when returned to normal usage. 

6. Review of existing site asset management plan to

  • Identify the associated plant and equipment to the designated surge areas to develop a temporary maintenance schedule to ensure ongoing service reliability 
  • Possibly include new and temporary requirements such as

 i.) Intermittent monitoring of oxygen concentration levels within each bed area via handheld device​

 ii.) Increased maintenance frequency to supporting infrastructure.

Appendix B – Draft process to follow

Adapting clinical spaces that are currently in use for patient care

In support of the main body of this DGN, this appendix outlines the process which is recommended to be undertaken to facilitate the conversion for a space that is currently in clinical operation. 

Suggested process steps include:

1. Site/ IPU/ unit is identified as designated surge capacity works.

2. Meeting scheduled with local nursing manager/ facilities manager to confirm that existing services are fully operational. If issues are discovered, these will need be investigated and repaired urgently. 

3. Review of all existing bed provisions in line with Section 5 of this Guide and:

  • Ensure a schedule of compliance/works to be completed and should be produced as part of the facility maintenance schedule
  • Recommend the completion of a capacity test for oxygen supply capability which will provide information to inform the assessment of bottled gas requirements. This will also inform required space requirements storage issues for bottles. 

4. Review building systems that support the department generally. For operating theatres that may have been rebalanced to achieve negative pressure environments, it should be noted that all existing settings of dampers, VSD's etc. should be locally marked and recorded to allow easier re-establishment when returned to normal usage.

5. Review of existing site asset management plan:

  • To identify the associated plant and equipment to the designated surge areas to determine/create a temporary maintenance schedule to capture increased service reliability 
  • To also include new, temporary requirements such as

 i.) Intermittent monitoring of oxygen concentration levels within each bed area via handheld device

 ii.) Increased maintenance frequency to supporting infrastructure 

6. LHD Capital Works teams to compile brief to outline required changes. This will likely involve Group 3 FFE and the associated timeline for completion. Infection Prevention and Control delegate with recognised expertise must form part of this group.

7.Brief submitted for approval to the facility General Manager / LHD Chief Executive

8. On approval to proceed, works may commence.

9. Execution of any/ all works as identified above may require:

  • Contractor to produce records or install/test sheets for any works undertaken.
  • For any services being recommissioned, LHD witnessing is to be offered for general services, Medical gas works must be witnessed as per Australian Standards.​​
 
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Page Updated: Friday 17 April 2020
Contact page owner: Health Protection NSW