SPACE

Recommendations to meet space requirements during a pandemic or crisis can be categorised in two main strategies:

1. Increase space capacity: by suspending elective, nonessential services, repurposing beds and departments, and creating additional temporary capacity (see 8.3.1).

2. Improve functional programming, access, and flow management (see 8.3.2).

Before going into depth in the options to implement these two strategies, we want to highlight an important prerequisite. In order to keep track of the availability of space, a system to monitor bed occupancy (including the number of patients in isolation), the number of rooms used for isolation, and

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the number of rooms that can be potentially used for isolation should be in place both at hospital and country level.⁶¹ This system can, once the number reaches a certain threshold, trigger the progressive conversion of normal rooms to isolation rooms, create cohorting departments, or set other strategies in motion. We elaborate on planning tools and models to monitor bed occupancy later in this chapter (see 8.7).

8.3.1 Increase space capacity

8.3.1.1 Suspend nonessential elective services

In order to increase the space capacity, several guidelines recommend to suspend all elective medical/surgical procedures and activities.^62-68 This should especially be done once community transmission of COVID-19 has been documented within a province or country.⁶³ The suspension of these nonessential services will rapidly increase the availability of staff (which can then be redeployed to assist in critical care provision, see 8.5.3.1) and repurposing of spaces to acute care delivery.^{69, 70} Despite its short term merit, nonessential services cannot be suspended indefinitely, because this will enhance the stress on the healthcare system in the long term. Cancelling nonessential services can increase the capacity substantially in the beginning of the pandemic or crisis, but if it is prolonged, this strategy may have to be re-evaluated.⁶⁹ In this respect, the National Academies of Sciences – Engineering and Medicine (2020)⁷⁰ recommend to determine prioritisation for procedures (for instance, by embedding a ranking system) or collaborations between hospitals in networks or coalitions. This could lead to the continuation of elective procedures in some hospitals, while others curtail them. However, the authors do not refer to existing ranking systems or tools to prioritise procedures in light of pandemics.

The role of healthcare coalitions and public authorities is important to maintain a coordinated approach in absorbing the surge. Healthcare coalitions (or networks) are, therefore, required to be consulted during the decision making on suspending nonessential elective services. But the actual decision is best taken by the public authorities to ensure coordination.

Table 19 – Options to suspend nonessential elective services

Recommendations References

Suspend all elective nonessential services (e.g.

medical and surgical procedures and activities) Anesi et al. (2020)⁶², Aziz et al.

(2020)⁶³, Christen et al.

(2020)⁶⁴, Hick et al. (2009)⁶⁵, Hick et al. (2020)⁶⁹, Thomas et al. (2020)⁶⁷, World Health Organization (2020a)⁶⁸

Utilise a ranking system for procedures to determine prioritisation

Collaborate in networks or coalitions to continue elective procedures

National Academies of Sciences – Engineering and Medicine (2020)⁷⁰

8.3.1.2 Repurpose beds and departments

When beds at the ICU are saturated, guidelines usually recommend a stepdown approach to convert or repurpose beds/departments. First, post-anaesthesia care units (PACU) beds or operating rooms are converted to deliver critical care.^{64, 71, 72} The necessary resources to deliver critical care (such as oxygen connection, ventilators, monitoring) are already available in these monitored procedural areas. Afterwards, beds in other hospital locations are repurposed for critical care in the following order: (i) use of step-down units and large procedure suites (e.g. gastroenterology labs), (ii) use of telemetry units (i.e. non-ICU rooms with vital sign monitoring), and (iii) use of hospital floor beds.^{62, 64, 71} If this repurposing is not yet sufficient to meet the care demand for COVID-19, non-clinical areas can be transformed in delivering (critical) care.⁷² Nevertheless, the overall objective should be to concentrate care for the most critically ill patients in the conventional critical care areas (such as an ICU) and move those patients that are more stable or with lower resource requirements to other areas of care.⁶⁶

Furthermore, hospitals should have a tiered plan in which initial cases are accommodated in Airborne Infection Isolation Rooms (AIIR).⁶⁹ This is mainly attributable for current COVID-19 pandemic (e.g. reverse isolation rooms will be necessary in case of nuclear disasters) and will especially be useful

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in the beginning of the pandemic. The number and location of potential beds to be re-assigned as AIIR rooms and a plan to re-allocate the non-isolated patients to other rooms is established.⁶¹ In first instance, all hospitals should maximise the number of single rooms in which a positive COVID-19 patient can be hospitalised (that can be transformed into double rooms in case of hyper flow of patients).⁷³ When there are no single AIIR rooms available, hospitals can progress to cohorting^uu multiple patients in one isolation room^vv (e.g. doubling up patients in ICU rooms) and subsequently to cohorting on specific designated departments.^{69, 71}

Table 20 – Options to repurpose beds and departments

Recommendations References

Convert beds and departments using a stepdown approach:

• post-anaesthesia care unit (PACU) beds or operating rooms to ICU beds

• other monitored procedural areas (such as gastroenterology labs, intermediate care) and monitored/step-down units

• telemetry units

• hospital floor beds

• transform non-clinical areas for care

Abir et al. (2020)⁷¹, Anesi et al. (2020)⁶², Bader et al.

(2020)⁷², Christen et al.

(2020)⁶⁴, Hick et al. (2020)⁶⁹

Cohorting of patients (tiered plan):

• hospitalisation of initial cases in AIIR isolation rooms

• cohorting of multiple patients in isolation rooms

• cohorting on specific designated departments

Abir et al. (2020)⁷¹, Anesi et al. (2020)⁶², Hick et al.

(2020)⁶⁹

uu Cohorting means grouping residents based on their risk of infection or whether they have tested positive for COVID-19 during an outbreak.

When designing new hospitals or refurbishing of existing ones, maximise the number of single rooms (that can be transformed into double rooms in case of hyper flow of patients).

Capolongo et al. (2020)⁷³

The number and location of potential beds to be assigned as isolation rooms and a plan to re-allocate the non-isolated patients to other rooms must be established.

European Centre for Disease Prevention and Control (2020)⁶¹

8.3.1.3 Create additional temporary capacity

When existing space capacity is insufficient, hospitals can opt to create/open new units or beds (additional, on top of the licensed number of beds) to handle patient flow.⁶⁵ In addition, deployable critical care services can be considered as a temporary alternative for critical care provision.64, 68, 71, 74, 75

“Temporary” because sophisticated critical care is most effectively provided in the regular hospital setting.⁷⁴ These deployable services could entail opening mobile/field hospitals, reopening closed hospitals, outsource care of non-critical patients to appropriate alternative treatment sites (e.g. home for mild illness, long-term care), or convert additional sites to patient care units (e.g. convalescent homes, hotels, schools, university dorms, community centres, gymnasiums). This has traditionally been used by the military but has only recently been integrated into the civilian setting in response to pandemics and crisis situations.⁷⁴ Contrary to military field hospitals, which primarily focus on trauma, mobile hospitals, when deployed in the civilian setting, should prepare to manage a dynamic and diverse case mix (including both surgical and nonsurgical patients). Because staff has to work more intensively compared to a regular civilian hospital setting (e.g.

longer working hours), nursing staff requirements may have to be higher than those required within a conventional hospital setting.⁷⁶ However, this creation of deployable care services also entails some important threats

vv If the hospital has rooms with negative pressure, the maximal number of patients that can be hosted in each room according to the manufacturer should be determined.⁶¹

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(e.g. in terms of patient safety) and should therefore only be implemented in real crisis-situations. Measures need to be taken to ensure safe and high-quality care delivery in these deployable facilities.

Table 21 – Options to create additional temporary capacity

Recommendations References

Create/open new units/beds (on top of the

licensed number of beds) Hick et al. (2009)⁶⁵ Create deployable critical care services, such as:

• mobile/field hospitals with ICU beds

• reopen closed hospitals

• outsource care of non-critical patients to appropriate alternative treatment sites (e.g.

home for mild illness, long-term care)

• convert additional sites to patient care units (e.g. convalescent homes, hotels, schools, university dorms, community centres, gymnasiums)

8.3.2 Improve functional programming, access and flow management

In order to manage the admission of incoming patients during a pandemic or crisis, hospitals can trigger mechanisms to transfer patients.^{65, 70} Admission and discharge criteria for patients should be developed in terms of available treatment capacity and demand.⁶⁸ When pressure on the healthcare system is increasing, ICU nurses and managers should be notified to start transferring stable patients with less resource demand (and cleared for release) to non-ICU departments. In addition, a list of potential

ww Triage of lifesaving resources is the re-allocation or discontinuation of services (such as ECMO or mechanical ventilation) due to its extreme resource commitment in times of shortage or saturation of the health system.⁶⁹

patients that could be admitted to stepdown departments, should be developed.⁶⁵ If appropriate, patients can also be transferred to other health centres or home care (see 8.3.1.3). For instance, treatment of the hospitalised elderly can be continued in care homes. However, the triggers for referring patients to other health centres or home care should be established.⁶¹ The clearance of rooms can be accelerated by placing cots to pre-designated discharge holding area/waiting areas to hold patients pending transfers.⁶⁹ As a last resort, transfer and diffusion of patients can be speeded-up by reallocating patients to bordering countries.⁶⁴

When healthcare systems are overwhelmed during health emergencies and resources are scarce, some of the guidelines refer to resource allocation by the triage of patients^ww.63, 68, 77 Triage algorithms for pandemics usually include the prospect of a time-limited trial (TLT)^xx period of therapy by recommending a re-assessment period between 48h and 120h. At this time, it is decided whether to continue critical care or to divert those scarce resources to another patient which is determined to benefit more.^79-81 There is currently no robust, long-term data on patient outcomes for COVID-19.

However, Aziz et al.⁶³ recommend a TLT period of 10-12 days. The TLT can be ended sooner when the condition is worsening and there are clear signs for unlikely survival. However, important to note is that early reports of COVID-19 patients suggest recovery is possible after prolonged periods of ventilation, so the time given to a TLT period of ventilation must be carefully considered. Nevertheless, when resource allocation by triage of patients is implemented, healthcare professionals should be protected by an adequate legal framework (see 8.6.3).

Related to the triage of patients is the decision regarding in-hospital placement of critically ill patients. For example, older persons already living in a nursing home can be quarantined and treated in the care home, rather than in a hospital.⁶⁴ This can be beneficial for the continuity of care and

xx A TLT is an agreement between clinicians and a patient/family to use certain medical therapies over a defined period to see if the patient improves or deteriorates according to agreed-on clinical outcomes.⁷⁸

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diffuses some of the impact on the hospitals. But the criteria for these decisions need to be embedded in legislation and the decision should be performed by an experienced clinician (who makes similar triage decisions on a daily basis).⁷⁴

Last, some of the guidelines recommend some architectural conditions^yy for hospitals to enhance access and flow management.61, 69, 73, 82 This is especially the case for the emergency department (ED), which is usually the entrance for suspected infected patients. When patients arrive at the ED, a

“parking lot triage” can be implemented, separating suspected infected patients from non-infectious patients.⁶⁹ Actually, the entire pathway through the ED should be separated for these patients.⁸² Furthermore, it is recommended to place ED and infections ward at the same level promoting short and horizontal connections and minimising the transmission of the virus to other people.⁷³

yy Other conditions to be considered when planning the building of new hospitals: strategic site location, typology configuration for enabling disease containment, create spaces with nature (real and on screen), recharge rooms for healthcare professionals to recover from a physically and mentally taxing shift, ventilation and air conditioning (HVAC) and indoor air quality (ensure

Table 22 – Options to improve functional planning, access, and flow management

Recommendations References

Adapt admission and discharge criteria according to available treatment capacity and demand

World Health Organization (2020a)⁶⁸

Transfer patients to diffuse impact

• Transfer stable patients to stepdown departments

• Develop list of additional patients that might be admitted to stepdown department

• Create pre-designated discharge holding areas or waiting areas for patients pending transfers

• Relocate patients to bordering countries

Christen et al. (2020)⁶⁴, Hick et al. (2009)⁶⁵, National Academies of Sciences – Engineering and Medicine (2020)⁷⁰

Resource allocation by triage of patients Aziz et al. (2020)⁶³, Maves et al. (2020)⁷⁷, World Health Organization (2020a)⁶⁸

Decisions regarding in-hospital placement of

critically ill patients Christen et al. (2020)⁶⁴, Einav et al. (2014)⁷⁴

Architectural conditions

• Separate entrance and pathway in the ED for suspected infected patients and non-infectious patients

• ED and infections ward should be placed at the same level promoting short and horizontal connections

adequate air exchange in all environments through mechanical, and where possible, mixed ventilation; heating, HVAC must be flexible and operation should be able to be modified).⁷³ Also, an additional place should be established that could be used as a morgue, if required, and where the custody of the bodies will be ensured.⁶¹

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