Like other healthcare systems across the country, Miami Jewish Health (MJH) needed to address COVID-19 on its main campus as the pandemic unfolded in the spring. The continuum of care campus includes a long-term rehabilitation hospital, hospice, dialysis treatment center, independent and assisted senior living communities, a 432-bed skilled nursing facility, and one of Florida’s PACE Center locations. Located in Miami, Fla., a hot spot for the virus, the campus was closed to all new patients and visitors by mid-March.
With minimal testing available early in the pandemic, MJH recognized the importance of creating an isolated location on campus to monitor senior living residents suspected of having COVID-19, as well as those residents who had tested positive. The organization’s leadership determined that its geriatric, non-surgical acute care hospital on campus was well isolated from other campus buildings and could house up to 32 patients.
This solution was short lived, however, when it became apparent that additional temporary COVID-19 wings would be needed, so the decision was made to convert the first two floors of the skilled nursing building. The facility had recently experienced a census drop, making units available, while the layouts of the nursing units, with a centralized nurses’ station and main entry/exit as well as exit stairs at the end of the units, allowed them to be converted easily to isolation units without creating exiting issues.
The portion of the facility dedicated for housing COVID-19 positive residents was isolated from non-COVID-19 residents by constructing anterooms within the hallways. Additionally, separate spaces were converted for donning and doffing rooms, further creating physical barriers between COVID-19 and non-COVID-19 care areas to protect residents and staff.
Creating insolation units
As planning for the isolation units progressed, Bloc 3 Design (Coral Springs, Fla.) partnered with TLC Engineering Solutions (Orlando, Fla.) to adapt MJH’s existing rooms to provide a safe environment for MJH residents who had been diagnosed or were suspected of having COVID-19. MJH reviewed a COVID-19 guidance document published by TLC Engineering and chose to use an option that included creating exhausted rooms and increasing air change rates, which would exceed the Centers for Disease Control and Prevention’s HVAC requirements.
The project team obtained cost-effective, individual room exhaust fans that allowed patient room air to be exhausted to the exterior of the building through room windows. Each exhaust fan was sized at 300 cubic feet per minute (CFM), which would increase the air change rate within the patient rooms to a minimum of 12 air changes per hour. A 25-foot barrier was created around the discharge of the exhaust fans to prevent contamination from the exhaust fan discharge.
With the exhaust airflow to patient rooms increased, additional outside air was required to prevent the building from going into negative pressure. With more airflow exiting the building than being introduced, MJH implemented two major changes to their existing HVAC system to accommodate the altered building system:
- Existing common areas, such as the nurses’ stations and dining areas, had supplemental HVAC infrastructure already in place that allowed outside air to be dehumidified. With the additional outside airflow being conditioned by the supplemental units, two portable HEPA-filtered air scrubbers were located at the entry to the new nursing unit to supply filtered air to the positive-pressure anterooms and then migrate that air into the corridor to supplement the air being exhausted through the patient room windows. When combined with portable HEPA-filter scrubbers, which are effective tools for filtering droplets and particles that can be carriers of viruses, dehumidified and filtered outside air was able to compensate for the negative-pressure patient rooms.
- The existing central plant chillers, supplying chilled water to the building’s air handling units, were ramped up to increase the chilled water flow rate and temperature by several degrees to temper the additional outside air coming into the building. Without this excess capacity in its physical plant, MJH would have had to bring in a trailer-mounted chiller unit to supplement its chilled water capacity, which would have required more time and effort to achieve the additional conditioned airflow required.
While these temporary measures were being planned, the project team communicated with the Florida Agency for Health Care Administration (AHCA) Office of Plans and Construction as required by state statutes and the Florida Building Code. The emergency nature of COVID-19 and the real-time need for these modifications led AHCA to allow for modifications to be made, provided that the design and drawings went through the document submission process and a subsequent field survey of the facility.
AHCA team members consulted and provided input to obtain construction document approval to proceed with the alterations. After the document review and approval process, the AHCA field survey team conducted a virtual survey of the facility and the temporary modifications, which passed the required 100 percent field survey process, allowing MJH to keep these solutions in place for the duration of the pandemic.
Through its efforts, MJH was able to establish four wings housing 52 COVID-19 patients and 14 patients under investigation for infection. All of the converted patient care areas were previously skilled nursing units with systems in place to provide care. Patients who required a greater degree of care or use of a ventilator were transported to nearby acute care hospitals. Following approval by AHCA, MJH was approved to accept stabilized COVID-19 patients from the community, helping relieve bed capacity at several nearby hospitals.
One of the critical lessons from the project was the need to evaluate changes holistically. Modifying HVAC systems or altering the means of egress may solve one problem while creating others. While modifications were achieved to create a safe environment for COVID-19 patients and caregivers, the building HVAC system also had to be fine-tuned to prevent the introduction of excessive heat or humidity.
Second, it’s also important to have a pandemic plan in place, which can help minimize reaction time while saving lives and dollars. This plan is carried out similar to the process that healthcare facilities use in developing an emergency management plan, starting in the C-suite and then informed by the clinical staff and facility managers. Having a detailed plan in place allows the facility to anticipate the various stages of pandemic development and manage the patient surge that will come when local caseloads increase.
Measures such as doubling up patient rooms from private to semi-private, and possible conversion of other units must be contemplated. For MJH, the third floor of its skilled nursing building remained an option for potentially opening 26 additional bed locations, should they be needed. Overall, the majority of MJH residents were able to recover on campus, reducing their risk and the healthcare system burden.
Aaron Johnson is managing principal at TLC Engineering (Orlando, Fla.) He can be reached at firstname.lastname@example.org. Christopher Sable is managing principal at Bloc 3 Design (Coral Springs, Fla.). He can be reached at email@example.com.