Cedric Steiner

When the Centers for Disease Control and Prevention (CDC) 

 for ventilating buildings on March 23, the agency might have had the upcoming summer in mind—the guidance provides commonsense air circulation measures.

Those measures call for ventilation system upgrades, improvements, and modifications to dilute potential contaminates. It is my advice that building managers seriously consider these measures, many of which are low cost and generate universal prevention measures.

I developed the table below based on the CDC’s updated guidelines which are, in turn, partially based on the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Guidance for Building Operations During the COVID-19 Pandemic.

Air changes/hour (ACH) is the fundamental principle that guides current ventilation efforts involved in infectious disease mitigation. Keeping this in mind, I have assigned a generic assessment of cost and mitigation value. Those I have assigned as highly effective are most likely to increase ACH in a localized area. However, this depends on many factors.

In addition, there are interesting emerging technologies as well as long-term solutions available. A qualified HVAC provider can provide information on some of the suggested ventilation techniques. Organizations that are interested in a whole system and long-term cost-effective approach should seek consultation and engineering approaches.

Cedric Steiner, NHA, MBA, is a licensed nursing home administrator in Lancaster County, Pennsylvania. Contact him at 

He is the founder and owner of GS International Healthcare, which offers advice to people building hospitals.

Articles

It is my advice that building managers seriously consider these measures, many of which are low cost and generate universal prevention measures.

Expert Charts CDC’s Updated Building Ventilation Guidelines

Coronavirus disease 2019 (COVID-19) found many long-term care facilities (LTCFs) splashed across the front page of national newspapers, but not in the manner that they desired. The well-cultivated images associated with beautifully groomed gardens and formal dining settings were replaced by exhausted care workers wheeling hospital beds to waiting ambulances. These gloomy images captured a severe health care crisis unfolding as quarantining Americans watched and wondered about their elderly loved ones. The LTCF industry watched expectantly as well. As these events unfolded, each organization wondered how they might sidestep a similar crisis, maintain care standards, and avoid an ensuing public relations storm. The efforts of each organization would rely on the ability to manage infection control within buildings, routines, and staffing structures all foundationally not inclined to prevent disease transmission. In retrospect, which organizational response model produced the best outcomes for infection control?

President Joe Biden’s pick for United States assistant secretary of health, then Pennsylvania’s Health Secretary Rachel Levine, MD, confirmed on May 11, 2020, that the state of affairs in Pennsylvania was so compelling that it warranted the removal of her mother from a personal care home.

 As the Pennsylvania’s governor’s choice in leading the pandemic response, Levine had a bird’s eye view of the unfolding crisis. The view from above showed that although only a minority of elderly individuals receive care at LTCFs, the pandemic had disproportionate effects in these facilities. By May 2020, of the COVID-19 deaths in Pennsylvania, 70% had occurred in LTCFs, and these locations accounted for 21% of the reported cases. These staggering statistics were enough for some family members to remove loved ones from facilities.

For those in the industry, removing residents was not an option. They would have to face down the systemic risks rooted in an industry lacking any significant innovation since its inception. These risks included buildings designed for efficient congregant living, communal dining, and shared overextended staffing. In defense of the nursing home industry, these risks are largely a byproduct of decreased assistance in the form of reimbursement. Thus, LTCF providers must continue to consolidate costs to manage historic and continued underfunding. According to a 2016 American Health Care Association report, the cost to nursing homes to care for Medicaid patients exceeded their actual Medicaid reimbursement by $25.43 per day in 2015. This means the average Medicaid resident would cost in excess of $27,000 over their expected 3-year care period.

Systemic risks associated with the intersection of long-term care and infectious diseases required a successful response in the form of a combination of robust measures. Facilities placated with business as usual, the checking-off of survey boxes, and hopes that daily Centers for Disease Control and Prevention (CDC), Centers for Medicare & Medicaid Services (CMS), and state health department guidelines would provide the organization protection, soon reported facility wide outbreaks of COVID-19 and accompanying deaths.

A robust response required an organizational structure with components previously in place and an ability to modify existing structures. The organization needed the ability to sustain and achieve new goals within short time frames. These included new regimes in sanitation, dining, laundry, cleaning, and supplies, among others. At the forefront was a culture of trust associated between employees and the organizations’ directors. Managers would need an established trust and support from those working within departments to maintain morale during difficult times. This trust would hopefully avoid extensive turnover and short staffing during a time when the organization needed to maintain high levels of care. Sadly, this has been a significant issue in long-term care, where a recent study in Health Affairs found that the mean annual turnover nationally for total nursing staff was roughly 128%.

The best prepared organizations had previous investments in disease prevention personnel. Outside the traditional medical team, 2 important roles include an infection preventionist nurse and a respiratory therapist. These roles, with the associated training and professional development, were required to provide competences in personal protective equipment (PPE) fitting and infection control practices. Respiratory therapists with hospital training and previous treatment experience in infectious diseases were a strong asset able to provide nursing facilities novel respiratory insight and treatment.

COVID-19 spread quickly in high-density congregant living spaces. Most residents live in shared rooms and have between 3 and 6 caretakers a day. The average resident has about 100 sq ft of living space with limited associated air supply. The entire air in this space is shared with others for 15-minute increments. Difficulties in communicating with the elderly necessitate close speaking. These circumstances present a ripe atmosphere for spreading respiratory diseases. Although residents were largely isolated from the broader population, their caretakers were not. Those organizations that could afford to decrease the interactions of infected individuals within stood the best chance of keeping the virus from spreading. Many measures attempted by organizations focused on this area of containment: screening staff and vendors, suspending or modifying visitations, freezing admissions, isolating residents in their rooms, dedicated isolation floors, masking, decreasing or prohibiting shared staffing between organizations. All of these measures had unintended consequences of isolating and depressing social interaction and thus the quality of life for residents, but they worked. They worked like a porous block of Swiss cheese (ie, James Reason’s Swiss cheese model [SCM]). Reason’s SCM model proposes multiple layers of protection like slices of Swiss cheese to manage risk. The more layers of protection (slices), the greater the likelihood of preventing the transmission of infections.

The timing of precautionary measures was an important contributing factor. Instituted too late, even the strictest of measures are bypassed by a spike in community spread. Records I collected in Lancaster County, Pennsylvania, revealed that facilities that instituted early isolation measures with extensive prohibitions faired the best at keeping the virus out of the facility. Had the pandemic been shortened, these measures might have provided significant returns. However, these early prohibitions were akin to a city under siege. They lasted for some time, but the virus ultimately seems to have “acquired” each facility.

The purpose and mission of long-term care is to provide life-affirming health care services to populations that have no other means or access to skilled care. However, hospital emergency departments and case managers relate stories of elderly individuals for whom they could find no accommodations during the pandemic. Some states had limited programs involving COVID-19–only facilities. This was an attempt to avert the commingling of hospital and nursing home populations. The low quality of the care and poor performance within these facilities has been a topic within CMS advocacy groups.

 Otherwise, skilled nursing facilities mostly closed their doors to protect internal populations. This was arguably a logical component to a broader infection control program. However, defying purpose by closing off resources to a community in urgent need of assistance and causing hospitals the additional burden of providing extended care during a health crisis is hardly a model approach. So, what could have been done?

One facility attempted a novel approach, which I hold up as a model in maintaining the essential purpose and mission of long-term care providers. The facility proactively established a negative pressure zone in its therapeutic center modeled alongside university research engineers. Nursing staff obtained training and expertise from a respiratory therapist with hospital experience in infectious diseases involving PPE and proper isolation techniques. Additionally, they consulted nursing staff at research hospitals operating COVID-19 centers. They then promptly began providing COVID-19 assistance to the elderly within their community, strictly within their designated unit.

The measure was proactive, and the facility experienced no COVID-19 cases outside of the designated unit for several months. During this time, the facility garnered experience in managing COVID-19 while keeping the virus isolated to a uniquely engineered zone. This experience in managing COVID-19 became a resource when the virus successfully “acquired” the facility after months of working through layers of isolation protections (SCM). The virus entered the facility not from the COVID-19 unit as some feared would happen, but a separate location most likely associated with staffing and community spread. The ensuing results were similar yet somewhat better than what other facilities experienced. The facility, sufficient in size with 114 beds, was one of the last in the associated area and broader state to acquire the virus outside its designated COVID-19 zone.

This novel approach is the only one I know of where a nursing facility was able to record assisting more COVID-19-positive residents within the community than it would have had original exposure to. This approach benefited community hospitals, prepared facility staff, and provided economic resources to the organization. The intent to provide this care and the labor and risk that this organization expended deserves recognition. It is to this that I commend Jerry Lile and the employees past and present at Fairmount Homes in Lancaster, Pennsylvania.

CEDRIC STEINER is a licensed nursing home administrator in Lancaster County, Pennsylvania. Contact him at steiner@gshealthcare.org to learn more about the use of negative pressure for immediate or future COVID-19 relief.

Fung, K. Pennsylvania health secretary moved mother out of nursing home as coronavirus death toll increased in state. 

. May 13, 2020. Accessed November 18, 2021. 

https://www.newsweek.com/pennsylvania-health-secretary-moved-mother-out-nursing-home-coronavirus-death-toll-increased-1503853

Long-term care trends and statistics. Pennsylvania Healthcare Association. Accessed February 25, 2021. 

https://www.phca.org/for-consumers/research-data/long-term-and-post-acute-care-trends-and-statistics

Gandhi A, Yu H, Grabowski DC. High nursing staff turnover in nursing homes offers important quality information.

. 2021;40(3):384-391. doi:10.1377/hlthaff.2020.00957

COVID-only nursing facilities: what happened to a good idea? Center for Medicare Advocacy. October 15, 2020. Accessed February 27, 2021. https://medicareadvocacy.org/covid-only-nursing-facilities-what-happened-to-a-good-idea/

Cedric Steiner is a licensed nursing home administrator in Lancaster County, Pennsylvania. Contact him at steiner@gshealthcare.org to learn more about the use of negative pressure for immediate or future COVID-19 relief.

Difficulties in communicating with the elderly necessitate close speaking. These circumstances are a ripe atmosphere for spreading respiratory diseases. While residents were largely isolated from the broader population, their caretakers were not.

How One Long-Term Care Facility Held Off COVID-19

The airflow in your facility may have been overlooked prior to coronavirus disease 2019 (COVID-19) but that has changed. When it comes to infection control and prevention, it’s time to focus on this critical element for patient and provider safety. Take a moment to consider where the air supply directly overhead comes from. Infectious agents or suboptimal environmental conditions, perpetuated by the air supply, will exacerbate infections.

To manage a highly transmittable disease such as COVID-19, organizations have used altered airflows, or more specifically negative pressure, within their facilities to increase air exchanges and optimize fresh outdoor air. I first became involved in such a project while serving at a skilled nursing facility. To manage the oncoming crisis and uncertainty associated with admissions, quarantine procedures, and hospital capacities, I worked with Shelly Miller and a group of colleagues at the University of Colorado to convert a rehabilitation hallway into a negative pressure space. We performed computational fluid dynamics and particle-based modeling to test containment. The isolation space was successful both in our model and in practice at controlling transmission between residents and staff.

 Due to the cancelation of elective surgeries and the subsequent pause in rehabilitation services, the negative pressure space provided an important revenue stream and community resource for older people requiring skilled COVID-19 nursing care.

When the Boston Globe recorded Steward Health Care’s preparations at Carney Hospital in Dorchester, Massachusetts, to make the institution the nation’s first dedicated coronavirus care center, Steward stressed the transformation of a floor into negative pressure.

 Carney designated a team of doctors and an operating room within the coronavirus care center to prevent transmission to the broader hospital population. But it was the negative pressure and separate airflow that was arguably the largest factor making it a “hospital within a hospital.”

Outbreaks such as the Ebola virus disease of 2014-2016 encouraged the thinking behind building designs to include the capability of achieving negative pressure over large areas. Engine ers at Children’s Hospital of Philadelphia foresaw a looming pandemic and designed their buildings with the ability to respond. Hospital officials can convert several floors into airborne infection isolation (AII) rooms, more commonly termed negative pressure rooms, with the flip of a switch. In the most recent pandemic, this innovation and foresight has proved to be tremendously beneficial.

According to Rachel McCarthy, vice president of plant operations at Children’s Hospital of Philadelphia, the hospital’s newest design has the ability to convert 2 floors, 3 wards, and more than 150 rooms to AII rooms. The building management system (BMS) uses computer software to adjust the mechanical and electrical equipment throughout the building to achieve the desired results. At the request of administration and the infection control and prevention team, this system can be turned on to achieve the desired airflows throughout the building. But this requires the necessary infrastructure. Controls, equipment, and sensors need to be installed and building management must be trained. I’m convinced these improvements should be a future investment in public health that should not only be in hospitals but in other health care settings, such as skilled nursing facilities. As McCarthy puts it, “Managing a pandemic without a problem requires [personal protective equipment], testing, and negative pressure,” a 3-pronged approach.

Nick Clements, PhD, is a lead consultant at WSP USA, a globally recognized professional services firm specializing in infrastructure, and an expert in building technology systems. He envisions a smart building with integrated infection controls. In a recent conversation, he outlined some innovations and challenges currently being explored in new building design across transportation, manufacturing, and health care. “Smart building,” or building automation, is used to denote buildings with integrated controls and data collection. This often involves the automation of multiple interrelated systems such as heating, ventilation, and air conditioning, electrical, lighting, access control, and security systems through a BMS. Imagine taking this a step further where patient data and health care provider information are integrated into the building. Clements discussed a scenario in which future infections would be identified rapidly before they could spread. This could be done through a BMS that contained integrated patient data and diagnostic technologies employed in monitoring airflows.

For example, microfluidic systems and biosensors, used for clinical diagnostic purposes, could be integrated into a building system to provide clinical data. One type, the local evanescent array coupled (LEAC) biosensor, uses optical immunoassay sensors that permit the detection of up to hundreds of target biomolecules and viruses.

 The chemical and biological engineering program at Colorado State University has a group focused on this technology. These sensors require no reagents, are low cost, and operate as a lab-on-a-chip with integrated circuits.

These diagnostic tools could alert building occupants and confirm the spread of an infection. An integrated BMS that contains pressure monitors could also adjust pressure zones and air supply, further protecting a region within a hospital. When combined with patient and health care tracking, this information could be used to identify the source of an infection. According to Clements, “the challenges of a smart building require the whole organization to innovate.”

Regulations
In a truly integrated BMS, many monitors and systems need to feed back into the control platform. Currently, these systems are often standalone or siloed in a BMS and require a control engineer to integrate the data—a significant burden. A cloud-based system could alleviate difficulties in staffing information technology technicians and data management scientists.

The current COVID-19 pandemic will spur innovation most likely in the direction of vaccines, testing, and airflows. When it comes to airflows, keep an eye on ANSI/ASHRAE/ASHE Standard 170-2017, which currently details guidelines for environmental controls within health care facilities. The standard, which establishes the parameters for ventilation of health care facilities, will need to guide decisions between infection control teams and building management. Standard 170-2017 allows retrofits to be made to convert standard patient rooms into AII facilities. Infection control teams should be in discussion with facility management on these possibilities if we are to expect any future improvement in managing infectious agents similar to COVID-19. I expect the future holds some exciting building management tools for the infection control preventionist. p

CEDRIC STEINER is a licensed nursing home administrator in Lancaster County, Pennsylvania. Contact him at steiner@gshealthcare.org to learn more about the use of negative pressure for immediate or future COVID-19 relief.

Miller SL, Mukherjee D, Wilson J, Clements N, Steiner C. Implementing a negative pressure isolation space within a skilled nursing facility to control SARS-CoV-2 transmission. 

. Published online October 3, 2020. doi:10.1016/j.ajic.2020.09.014

Ellement, JR. Carney Hospital in Dorchester establishing COVID-19 treatment center.

. Updated March 17, 2020. Accessed November 12, 2020. https://www.bostonglobe.com/2020/03/17/metro/carney-hospital-dorchester-establishing-itself-covid-19-treatment-center/

Yan R, Kingry LC, Slayden RA, Lear KL. Immunoassay demonstration using a local evanescent array coupled biosensor. Proc SPIE 7559, Optical Fibers and Sensors for Medical Diagnostics and Treatment Applications X, 75590D. February 24, 2010. 

https://www.deepdyve.com/lp/spie/immunoassay-demonstration-using-a-local-evanescent-array-coupled-Xylq7XAjyw

Bioanalytical Microfluidics Program. Colorado State University. Accessed November 20, 2020. http://navier.engr.colostate.edu/research/index.html

Officials at the Children’s Hospital of Philadelphia have the ability to convert several floors into airborne infection isolation rooms (AII), or more commonly termed negative pressure rooms, with the flip of a switch.

Cedric Steiner

Articles

Expert Charts CDC’s Updated Building Ventilation Guidelines

How One Long-Term Care Facility Held Off COVID-19

COVID-19 Pandemic Proved Importance of Airflow in Buildings