Cedric Steiner: “We had to address the ability to say good-bye to loved ones. A big guy, with tears in his eyes. He was so thankful that they had a place to go for their mother, because at the hospital they couldn’t see her. He wanted to give me a bear hug, but we did the ‘elbow thing’ instead.”
In late March 2020, Cedric Steiner was keeping watch on the case numbers of a new threat to nursing home residents: coronavirus disease 2019 (COVID-19).
Steiner was interning at a nursing home in Lancaster County, Pennsylvania, completing state and federal requirements for a license as a nursing home administrator. The facility’s COVID-19 task force, which he served on, was looking for solutions to what seemed an inevitable crisis. The Pennsylvania Department of Health “epi curve” chart showed that cases in that state were spiking scarily fast, from just a handful at the beginning of March to 40 and climbing within a couple of weeks.1
Reading everything he could get on how to protect nursing home residents and healthcare workers from COVID-19—particularly scientific solutions—Steiner came across a 2017 study led by Shelly Miller, PhD, and Nick Clements, PhD.2 In it, they described how they had turned a regular hospital unit into a negative-pressure isolation space virtually overnight by modifying the existing HVAC system.3
Could something like that work for a larger area—say, an entire wing of a nursing home? With a potential pandemic looming?
Steiner reached out to Miller on March 28 to ask if she’d be willing to help his nursing home replicate what she and Clements had done.
In short, the answer was yes.
Negative pressure isolation space is an effective method to meet needed surge capacity during a healthcare crisis like the COVID-19 pandemic, Miller has written, and being able to create it rapidly is a boon, especially in nursing homes and other congregate living areas. She and Clements had shown that “rapid” means “rapid”—in 24 hours they converted a 30-bed hospital ward to an airborne infection isolation area in anticipation of a flu pandemic.
Steiner broached the idea to the task force, which included the CEO, vice president of healthcare, director of nursing, and infection control nurse. It wasn’t an immediate sell, he acknowledges. But after he rounded up donations in materials and money (including from himself) to reinforce the feasibility, they were willing to try it. Valerie Hatt, RN, the infection control nurse, says, “I wasn’t sure that we would have the capability, but our environmental services director is very knowledgeable and thought it could be done.” She notes that the respiratory therapist also thought it was a good idea.
Nursing homes designed on a hospital model (ie, with rooms branching off central corridors with corresponding HVAC systems) are architecturally able to sustain negative pressures that meet or exceed CDC guidelines, Miller says. The hall being modified in this case is on the bottom floor of a wing of a larger building. It had 13 beds within 7 rooms, 6 double-occupancy rooms, and 1 single-occupancy room, each with a single bathroom. The single-occupancy room included an anteroom with a separate sink and medical cabinet. The rooms each had a sealed solid glass window facing the hall and an exterior window. Heating and cooling were self-contained in each room with designated units, fans, and air ducts.
The director of facilities, John Becker, determined that he could make the necessary adaptations to the HVAC system similar to those done in the Miller study. The engineering and environmental services teams began the HVAC and plastic barrier modifications on April 2 and finished on April 6. They added 2 new blowers, turned off the incoming outdoor ventilation fan using a breaker, and mounted an exhaust to the outside of the intake grate on the side of the building traditionally reserved for incoming outdoor ventilation, thus reversing the flow of air and converting the hall to 100% exhaust. They removed the preconditioning unit of the energy recovery ventilator and closed the fire damper. Originally, HEPA filters were placed in the energy recovery ventilator (ERV) but, due to restricted air flow, these units proved prohibitive. The solution, Miller says, was to use Minimum Efficiency Reporting 8 filters and cordon off a 15.2-meter radius around the exhaust vent on the east side.
They installed 2 sets of 3-sheet plastic barriers to construct a temporary anteroom (the fire door was still usable). The barriers were rolled at the bottom just above carpet level and taped at the sides to identify separations for healthcare workers to access. The anteroom contained a 240 clean-air-delivery rate HEPA purifier fitted with ductwork to exhaust air into the hallway and toward the extremity of the wing.
In 4 days they had created a “cascade” of negative pressure zones between the isolation space, the anteroom, and the rest of the facility.
Once it was all in place and operational, they left it alone, Steiner says. “It worked very well from the outset. We didn’t adjust anything after that point on the timeline.” Acting as the go-between—the “boots on the ground”—Steiner went to meetings and “conveyed suggestions,” collected data, and made sure everything was working.
A lot of things took on significance they hadn’t had before, such as wind. One day, Steiner recalls, they had fierce winds, with the alarming prospect of blowing virus particles into the rest of the facility. But that never happened, he says. According to continual data being recorded on a laptop, even with high winds it all kept working just fine.
The respiratory therapist gave nursing staff (RNs, LPNs, CNAs), nurse practitioner, and physical therapy staff who needed to enter the negative pressure space a 2-day training in donning and doffing protective equipment (PPE). The nurse practitioner conducted the SARS-CoV-2 testing. By April 6, Steiner says, everyone was operating on a higher PPE standard than in most similar settings.
Then, on April 8, they had to put it all to the test: The nursing home accepted its first COVID-19-positive patient. Steiner says the facility was unusual in this, as the only nursing home taking in COVID-19 patients in those early days of the pandemic. They were seen as “reckless,” he says: “Why are you doing this? You’re endangering everybody.”
But the specialized unit, Steiner says, offered patients who went through the “revolving door,” from nursing home to hospital and back, a place to quarantine safely in familiar surroundings. The healthcare workers also saw the isolation unit as a safe space—they were requesting to work there, in fact, Steiner says.
“As we took on COVID-19 patients from the hospital setting who were on the mend, it seemed like we had a good thing going,” says Hatt. “We didn’t have any ourselves.”
Miller, Clements, and Steiner, along with Debanjan Mukherjee and Joseph Wilson, from the University of Boulder (CO) environmental engineering program, began collecting data on May 14 for a study on the nursing home project.4 Two to 4 known patients with SARS-CoV-2 were being treated in the isolation space during the study. From April 8 on, the facility had no known positive result within its own population. None of the healthcare workers assigned to work in the isolation space presented with symptoms or tested positive thereafter. Mandatory testing on July 24 revealed some asymptomatic staff and residents, but Steiner says to his knowledge, as of early September, “COVID never came out of that place.”
The isolation unit and the rest of the facility had different experiences. “We had an outbreak on the second floor,” Hatt says. “We took some of the residents downstairs to the COVID Hallway, but then started to treat in place, not wanting to move them through the building. We lost 11 of our own residents.” Among those lost was Hatt’s own mother, who had asthma when she contracted the virus.
So, was the project successful?
Again, the short answer, from those involved, is “yes.” The isolation unit isn’t meant to be permanent, Steiner says. It was meant to serve an emergent need, to protect healthcare workers and give patients a safe place to be treated.The bonuses, as the researchers pointed out, were that the community benefited from the expansion of available health services and reduced community spread in facilities that lacked sufficient mitigation strategies, and residents were spared the stress of transfers to and from emergency facilities.
As for lessons learned, Hatt says, “Both nursing and non-nursing staff learned the proper way of wearing isolation gowns. Also, we didn’t have a reason to use N95 in the recent past and are now comfortable with fit testing and wearing N95s.” Moreover, “I think staff all learned new or refreshed seldom used procedures and will be more aware of spreading infection and how to prevent it in the first place.”
Miller says, “From my point of view, the only thing we could have improved was more pressure measurements (we only had 1 device to do the pressure measures) and the ability to measure the outdoor air ventilation rates in each room on the hallway. Oh, and try to make the bathrooms more negative with respect to the rooms, but that is much harder to do.” The researchers also suggest adding upper-room germicidal ultraviolet lights within the area to inactivate any airborne virus, and using air purifiers to exhaust air from each room to the outdoors.
The man who initiated the project, Steiner, says many of his business classes focused on caring for employees. “I felt you had to give your clinical workers the best situation so they could succeed.” But “the emotional side of this can’t be lost, even in a dynamic, unique situation. We had to address the ability to say good-bye to loved ones.”Making it possible for family to suit up in PPE to spend valuable time with their relatives meant a great deal to them, Steiner says. He remembers one son: “A big guy, with tears in his eyes. He was so thankful that they had a place to go for their mother, because at the hospital they couldn’t see her. He wanted to give me a bear hug, but we did the ‘elbow thing’ instead.”
Thanks to this on-the-job experience, Steiner and a partner are now working on projects to help facilities manage isolation solutions and infection control. He wants to design buildings with the same “on-off deal”—that is, flexible designs that allow areas to be converted into negative-pressure as needed. “We have to make a healthy building. We have to make an environment that’s protection for residents and healthcare workers.”
JAN DYER is a writer and editor specializing in clinical topics. She lives in Suffern, New York.