Abstract
Abstract
The novel corona virus has reached the pandemic levels since March 2020. This has exerted tremendous pressure on existing infrastructure. Amenities related to quarantine and isolation are new norms in healthcare set-ups all over the world. The present study helps to understand the guidelines needed to change the current available infrastructural resources of essential departments in addition to forecasting and organizing the infrastructure required to cater the special needs of the COVID-19 patients without compromising the smooth functioning of the healthcare facility and not risking the safety of the health care professionals delivering it.
Introduction
The Novel Corona Virus or COVID-19 caused by SARS-CoV-2 has reached pandemic levels since March 2020. Due to the absence of vaccine currently and ongoing research in this field, the pandemic has already exerted tremendous pressure on the healthcare infrastructure around the world. India being a developing country and having limited resources pertaining to healthcare faces even greater challenge. Coupled with increased demand and utilization of Intensive Care Units, Isolation Facilities, Ventilators, Surgical Beds and Personal Protective Equipment’s it has really brought to the fore the humongous gap of service availability and its demand leading to crisis like situation on multiple fronts. This situation has in a way shown the importance of planning beforehand, timely recognition and complete utilization of resources (Allahi 2015).
Additionally, many parts of the world today suffer due to shortage of funding in healthcare, lack of healthcare infrastructure in semi- urban and rural arears and insufficient planning of health facilities. This therefore has led to mounting up of difficulties other than absence of vaccine and curative care options in regards to COVID-19 pandemic.
The world currently, is in grave emergency and the most valuable asset during this time is are the healthcare workers trying to convert the hospitals and alternative health care providing amenities into Covid19 hospitals and wards (Centers for Disease Control and Prevention 2020; Government of India Ministry of Health & Family Welfare Directorate General of Health Services (EMR Division) 2020). Thus, it is of prime concern to have a smart and efficient plan that helps to successfully nurture the patients as well as have minimum mental and physical exertion to the healthcare staff while performing the duties.
WHO declared COVID-19 Infection as Global Pandemic in the month of March and all the countries are guided for Emergency State and prompt provision of guidelines for early identification via clinical testing, containment and isolation efforts for restricting the spread of Corona virus infection. Various important thresholds are considered but in them is also the separation of grouping activities, identification separation of positive cases and coming up with treatment as no vaccine is available (MOH GOI 2020).
This has led to making the facility for quarantine and isolation made available on a large scale at all the prominent healthcare facilities of the country. Quarantine is the separation and restriction of motion and activities that includes interaction with other people be it verbal or physical and is confined to a limited area so as to minimize the spread of infection (MOH GOI 2020).
The study is mainly centered on the changes that area unit expected to be created within the available infrastructure of the Hospital (Centers for Disease Control and Prevention 2020). The mandatory guidelines provided by numerous authoritative bodies along with healthcare accreditation bodies are studied and the essence of them with respect to various departments has been compiled in this study (A/llahi 2015).
This study comprises a sense of directional aid than guidelines, the recommendations are made on the basis of observations and discussions with healthcare experts at the forefront of the COVID-19 pandemic. The area designs, requirements or modifications suggested are limited to the time of pandemic, and for the healthcare facilities in a certain demography and in no regards to be considered mandatory to alter the premise as per recommendations (Ministry of Health and Family Welfare Directorate General of Health Services 2020).
Aim
To plan the infrastructure of a 250 bedded COVID-19 facility by making comfortable infrastructural modifications to minimize risk of infection amongst patients, healthcare workers and administrative staff.
Objectives
To plan the modifications in the existing infrastructure of the facility within the guidelines and norms set for current pandemic situation.
To suggest for a safe and well-designed infrastructure with an isolation facility.
To minimize the risk of infection with changed infrastructural changes.
The key objective of this study is to plan the modifications in the available infrastructure of the facility. So that the guidelines and norms set for current pandemic situation will be easily followed. The intention to provide interim guidance for a safe and well-designed infrastructure with an isolation facility is to ensure that the risk of spreading of the infection within the facility is prevented and the safety and hygiene of the healthcare workers is not compromised.
Many studies highlighted that -it is the safety of healthcare workers that should be considered as important as any patient coming for the treatment. The hectic schedule and unending chain of patients have put a great deal of burden both physical and mental on healthcare workers. Any step in the direction to make their service delivery easier will be beneficial.
An attempt has been made through this study to compile the essence of all the guidelines into a single one with respect to different requirements from across the departments of a healthcare facility. This is done with the intention to make the response of healthcare service delivery faster and preventing any loss of time and life due to infrastructural difficulty.
The study is framed after studying the major guidelines and norms set by the peremptory firms in the field of healthcare hence setting up standard of care to be provided on the least side is presumed while designing of it hence the modifications suggested are authentic and surely competent for a running midsize healthcare facility of 200-250 bed capacity.
The objective of making a seamless conversion of a running healthcare facility into a COVID-19 facility is one of the main objectives. This change should be done without putting undue strain on the minds of the healthcare workers in the facility and should complete all the expectations of the patients with respect to the treatment. The layouts give a general view of the positioning of modifications to be expected for the conversion into a COVID-19 facility.
Materials & Methods
It is a comprehensive study in which operational planning of hospital infrastructure is the main focus, so as to cater the current requirements of the global pandemic. The planning of infrastructure under this study is done carefully keeping in mind the guidelines set by worldwide organizations. The guidance for converting a given existing health care facility into a facility providing treatment for Covid19 hospital with a holistic approach for careful planning of different departments which will help in fast recovery of patients and at the same time keep the staff safe from getting infected.
The analysis technique that is used is with systematic technique with a fixed procedure of collection only verified and published data that can be relied on for the authenticity. Nevertheless there is lack of the quantity of articles that could be referred to due to the very specific requirements of the study and of a narrow timeline, many more modifications might arise in near future as research continues (Ministry of Health & Family Welfare Directorate General of Health Services, EMR Division 2020). Thus, this paper proposes a suggestive method that might provide relief on current situation.
The main point on of secondary analysis is to gather the theoretical data and verify using the research showing practical implementation of it and analyzing the feasibility of these figures with respect to the collected information. Comparison with the available resources considering the demographics, economics, literacy rate, age group and density weather the suggestions could be applied or not, and if not, what alternatives could be used to mitigate the risk; is the second step. The final and most crucial part for the secondary analysis in the study is that the suggestions are presented in a way that they can implemented and the authenticity remains intact while presenting the solutions (Johnston 2014).
Study Approach
The study is having a basis of secondary data analysis that has been done in the period from the months April to July due the restrictions of being physically present, experiencing and traveling due to the nation-wide lockdown prompted it to be done largely in an online mode. Various guidelines on infrastructure, similar research articles were studied. A detailed conversation with civil engineers of prominent hospitals of the same city was also done. The amalgamation of theory, practice and available guidelines helped in compiling the various aspects determining the essential changes needed to have better preparedness during any sort of pandemic.
Departmental Modifications
The planning of infrastructural modifications is further discussed department-wise, this helps separating the clinical services and supportive services. Separation of these is necessary as planning for both needs to be done according to the needs and available infrastructure.
Thus, the order followed with respect to discussion is as per the patient flow, with a view that patient enters from the triage and how the journey would go up to the discharge of the patient and what kind of planning will ensure safety of the staff and work efficiency.
Changing Room with PPE Facility
The safety of staff is of utmost importance, the planning of infrastructure is being done so that it becomes easy for the staff for functioning without being exhausted and taking care of safety (WHO 2020). The staff has to be completely covered by Personal Protective Equipment (PPE) when even in the premise of a COVID-19 facility. The chances of being infected is maximum while taking of the PPE and thus the PPE might have the virus on the surface. So, the changing room where the staff should change and put on PPE is planned keeping the importance and risk in mind (Directorate General of Health Services Ministry of Health & Family Welfare Government of India 2012).
The modifications and suggestions for the changing room are designed keeping in mind the requirements of the current situation and might seem space consuming but are of utmost importance and great necessity. Following are the points explaining the need for a changing room for donning and doffing of PPE for the hospital staff:
The changing must be separated in two parts with a partition, one where the staff enters wearing the normal wear that they are using and changing into the uniform which will be sterile, second side where they will wear the PPE and entering the department for their duty and the third side will be for doffing of the PPE (WHO 2020). The three sides are kept separate in order to main the sterility and preventing the infection.
The entrance where the staff comes in will have a sanitizer trolly, washbasin and waste bin other than a washroom. The washroom will be equipped with a running water tap and toilet. A storage unit to keep the clothes and a separate one for shoes. These will be separate for male and female staff members.
The Sterile side with PPE storage unit should have enough space for putting up the PPE, and this side will open into the department side and changing room side but will be totally cordon off from the third compartment.
The PPE doffing side should have assorted waste bins to discard off the PPE. PPE will be discarded off as per the guideline provided by the WHO and these are to consider them as biohazardous material for disposing purpose. There should be provision for a washbasin with soap and sanitizer trolly. (Refer Figure 1) (Mohammad Behnam et al. 2020) with appropriate alcohol-based hand rub/sanitizer.
Published online:
22 December 2020![]({"type":"image","src":"/na101/home/literatum/publisher/tandf/journals/content/vhos20/2021/vhos20.v099.i02/00185868.2020.1859343/20210705/images/medium/vhos_a_1859343_f0001_c.jpg"})
Figure 1. Layout of changing room.
Triage
Triage is classification and priority of determining treatment for the patients based on the severity and priority of need. Now triage is basically seen in the Emergency Department of the hospital but as the document provides guidance for a Covid-19 Hospital, the patients directed to the facility are either suspected or infected and hence are advised to get themselves checked or treated as per condition. Hence the triage is the very first point inside the hospital to receive such suspected/infected patients. The triage should be designed to have access and exit that will lead to the Fever access area for the further examination (Mohammad Behnam et al. 2020).
Following are the guidance points suggested to have at the Triage:
It is advised to have the triage at the very entrance of the hospital premise. This will help in directing the patients without compromising with the discipline of the facility.
There should be a separate entrance and exit for the patients, with it being a negative pressure room. Exits for patients must be after examination cubicle to avoid any confusion.
Separate entrance for staff with a Changing Room and adequate supply of PPE storage.
The patients on arrival will be directed toward the Mask Tent where they will be given hand sanitizer, mask and gloves if not properly equipped. The registration desk, which for this area should be set up as a temporary set up inside the triage unit along with spare masks and gloves.
The waiting area should have numbered benches with 1m distance between them.
A triage examination cubicle is curtained with a view to maintain the privacy, patient and doctor side will be separate with separate sanitization trolly. The doctors will be advised to examine mostly by asking questions and contacting the patient only if necessary.
A washroom and a separate washbasin must be available for patients which should be disinfected after each use as per the government guidelines. A PPE trolly nearby is advised in case the provided PPE to patients gets ruined. (Refer Figure 2).
Published online:
22 December 2020![]({"type":"image","src":"/na101/home/literatum/publisher/tandf/journals/content/vhos20/2021/vhos20.v099.i02/00185868.2020.1859343/20210705/images/medium/vhos_a_1859343_f0002_c.jpg"})
Figure 2. Layout of triage.
Clinical Lab for Covid-19
For the laboratory department, the intention is to keep it exclusively for testing of Covid-19 samples now due to heavy caseload (Government of India Ministry of Health & Family Welfare 2020). The dimensions can be conceded keeping in consideration the availability of space. Multiple guidelines are referred to before designing the lab to minimize the compromise in staff safety, maintaining the hygiene and to obtain maximum accuracy in the test results (MOH GOI 2020). Following are the recommendations:
The lab must be divided in three sections: Sample collection area, Testing area and Discard area.
The entrance and exit for patients will be the same, entry is restricted to sample collection area. A separate entrance for staff where a changing room is available equipped with PPE.
The lab should be designed as a negative pressure lab with one-directional flow from sample collection to discard point. The entry will be through air lock.
The lab should be equipped with storage for all PPE’s at the entry point and with under counter storages for reagents in sample collection area to utilize maximum available space.
The planning also considers for dedicated space needed for equipment’s used for storage and processing of samples, chemicals, reagents etc. which includes - refrigerator of 4 Degree C, frost free freezer, centrifuges 4 Degree, vortex mixer, certified class 2 BSC Type A2, autoclave, real-time PCR with workstation, computer with printer and sink.
Discard area is segregated from main lab and all waste coming from here will be treated as biohazard waste as per the guidelines (Figure 3).
Published online:
22 December 2020![]({"type":"image","src":"/na101/home/literatum/publisher/tandf/journals/content/vhos20/2021/vhos20.v099.i02/00185868.2020.1859343/20210705/images/medium/vhos_a_1859343_f0003_c.jpg"})
Figure 3. Layout of clinical laboratory.
Isolation Wards
Isolation wards provide mainly for the segregation of clusters and helps in deciding the treatment for patients tested positive for Covid-19 and are kept in isolation facilities until they are tested negative at least three times consecutively as per the government guidelines (Government of India Ministry of Health & Family Welfare 2020; Ministry of Health and Family Welfare Directorate General of Health Services [Emergency Medical Relief] 2020) The patients recovering and tested negative should be allotted different rooms to minimize the spread of infection (India. NCfDCDGoHSMoHaFWGo 2020). Hence, it is very crucial to have a design that will look after all these requirements. Following are the recommendations:
Negative pressure rooms with more than 12 rounds of air changes and if available separate rooms to be provided to the patients.
It is suggested, area of minimum two thousand square feet per ten beds with at least six feet distance between two beds.
Various signages depicting caution and isolation area must be posted on the outside in English as well as in the native language.
Separate entry and exits is necessary with waste bins, changing rooms, hand sanitizers.
Visitors should be strictly prohibited.
There must be access to testing area, emergency wards, stair cases and ICU. Neonatal ward, maternity ward, surgical ICU should be at a safe distance, preferably different floor or wing from isolation wards.
Patients should be allowed with minimum belongings. Separate utensils and bedding with utmost safety and cleaning protocols should be followed disallowing sharing under any circumstances.
About biomedical waste, signage should be at prominent places and clearly visible indicating the space, its segregation and should be lined with specific colored linings. Further care should be taken to clear the bins at certain intervals on regular basis during the day.
The hand laundry and sterile equipments must be accepted and should be stored in sterile area and cabinets only, negligence of any kind should not be tolerated (Figure 4).
Published online:
22 December 2020![]({"type":"image","src":"/na101/home/literatum/publisher/tandf/journals/content/vhos20/2021/vhos20.v099.i02/00185868.2020.1859343/20210705/images/medium/vhos_a_1859343_f0004_c.jpg"})
Figure 4. Layout of isolation ward.
Intensive Care Units (ICU)
The intensive care unit is the key department taking care of infected patients in critical condition during this pandemic. The staff are at much higher risk of contracting the disease while serving patients. The continuous increase in number of patients since last few months have already taken a toll on the staff mentally and physically. The space planning and infrastructure requirements should be planned in a way to minimize the existing fatigue level to a considerable extent (US Department of Health and Health Services and Centers for Disease Control and Prevention 2020). Considering the norms, modifications for intensive care units must look after safety and fast recovery of patients as well as, wellbeing of healthcare workers (Ministry of Health and Family Welfare Directorate General of Health Services [Emergency Medical Relief] 2020). The suggestion on infrastructure principally keeping the above points in mind are:
The ICU must be air conditioned and the humidity levels should be monitored, negative pressure is a mandate.
The entrance and exit must be separate with a fully equipped Changing room at Entrance will be advisable.
The ICU beds must be sufficiently spaced, if infrastructure permits, not more than three beds to be accommodated in a room. This will ensure efficient monitoring of patients.
Recovering cases to be moved immediately once out of danger, ensuring availability of ICU beds.
Maintain separate storage room and equipment rooms. Storage room for clean linen, consumables, prescribed drugs with a checklist of items which could be briefly exhausted.
Equipment room must have enough units of PPE, instrumentation (e.g., Ventilators, Suction Device, Continuous positive airway pressure, Resuscitator), consumables, and prescribed drugs. Daily rounds of checking and calibration must be performed. In case of any breakdown, biomedical department to be contacted immediately and a spare device must be deployed.
All the non-essential furniture is suggested to move and only essential and simple furniture must be present.
Washrooms must be disinfected after every use, as per norms.
Any visitor, if allowed, must be in complete PPE and follow the norms (Figure 5).
Published online:
22 December 2020![]({"type":"image","src":"/na101/home/literatum/publisher/tandf/journals/content/vhos20/2021/vhos20.v099.i02/00185868.2020.1859343/20210705/images/medium/vhos_a_1859343_f0005_c.jpg"})
Figure 5. Layout of intensive care unit (ICU).
Conclusion
Pandemic are recurring phenomenon. There will be another one, in our lifetime. It is pertinent to take lessons from this one to prepare ourselves better to tackle challenges similar to what we are facing today. India being a country on its growth path will face infrastructure challenges in time to come. It is crucial to incorporate the changes suitable to handle safety and medical care protocols with these infrastructural modifications. The vaccine being under trial phase is still far away from reaching each one. Until that time, such modifications may help reduce the burden and fear o spread of infection in hospital settings. Easing the process and work force flow with small but effective changes may go a long way to reduce the disease burden. The study has revealed that the healthcare facilities should strive to prevent its health workforce workers from nosocomial transmission, physical fatigue, and psychological issues that may be aggravated by the need to settle on morally troublesome choices on the proportioning of escalated care (Ministry of Health and Family Welfare Directorate General of Health Services [Emergency Medical Relief] 2020). It has brought to the fore facilities and planning required for quarantine facilities; modification needed in existing healthcare facilities catering to covid-19 patients. This is a study, which is suggestive in nature, which has been developed after observing the current practices followed in the healthcare facilities. The current infrastructure of many healthcare facilities to deal with Covid-19 is temporary and prospectively designed on available information and guidelines, which is limited as disease related information is still evolving. This study doesn't override the individual responsibility of health professionals to create acceptable choices within the circumstances of the individual patients, and also the final choices regarding a private patient should be created by the physician(s) accountable. The suggestions provided ought to in no way impede with recommendations provided by native and national health care authorities across the world (Ministry of Health and Family Welfare Directorate General of Health Services 2020). The suggestive modifications in the study is provided by different healthcare accreditation bodies after reviewing the clinical and administrative reforms to maintain the staff comfort while providing tireless patient service.
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