Public Health Emergency Preparedness
This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.
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Chapter 2. Facility Structure and Status
During the investigation of the two partially-shuttered hospitals, site, structural components, layout, fixed equipment, and utilities were assessed in light of potential for surge capacity use during a catastrophic event. This section of the report presents findings regarding location of the facility, access, and building infrastructure and critical systems. The Facility Checklist accompanying this report contains checklists used by the project team during inspection of these two hospitals.
Recommendation: A systematic assessment of candidate facilities should be conducted in advance to determine strengths/weaknesses of each and whether this is a feasible option for a given municipality.
2.1 Location and Access
Both hospitals are located outside the city's core metropolitan area and thus would likely be outside of the area of impact of a catastrophic event barring an atomic detonation. The hospitals are also relatively close to the city, within 30 minutes driving time and 10 miles, so that transportation of patients, staff, and equipment from the metro area would be readily feasible.
Roadway Access and Security
One of the partially-shuttered hospitals has access via two roadways and the other via three. This would provide continued access to the hospital in the event that one roadway became blocked or inaccessible. Both hospitals are located a short distance from regular thoroughfares on relatively large land sites. This requires long, connecting roadways that go only to the hospital property. It would be relatively easy to set up traffic stop points to limit access and check personal identification or vehicles if needed during surge use.
Vehicle Access and Parking
Roadways to both hospitals are large enough to accommodate cars, ambulances, buses, and trucks. More than ample parking was available at both facilities.
Both hospitals have small ambulance bays, allowing for unloading of one or two ambulances at a time. This would necessitate coordinated or staged scheduling for receiving patients on gurneys unless the loading docks were used for ambulance traffic as well.
Both hospitals have small loading docks. Hospital 1 could accommodate up to four 18-wheelers at a time, while Hospital 2 could likely only accommodate one or two at a time because space is adequate only for angled back-in. This would necessitate coordinated or staged scheduling for receiving equipment shipments from trucks. Hospital 2 also has a second, smaller receiving area for the cafeteria. Both hospitals could receive four or more vans at a time at the loading docks.
Both hospitals could receive helicopters. Hospital 2 has a helipad in the former nursing school parking lot that is a short distance down the access road. The back parking area at Hospital 1 could readily function as a helipad.
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2.2 Building Security and Life Safety Systems
All locks and alarm systems are in place and functional at both hospitals. Exterior windows, doors, and other structural components are in place, with no breach in exterior structural components allowing for building access other than in normal doorway entrances.
Both hospitals have a limited number of building entranceways (approximately a half dozen or fewer) that are readily controllable for security purposes. Both hospitals currently have on-site security staff. Hospital 1 currently has security guards around the clock, while Hospital 2 has security guards from approximately noon to 10 p.m. This security staff could likely continue to serve as security during surge use but would need to be augmented.
Life Safety Systems
Both hospitals have maintained operational life safety systems such as fire alarms and sprinklers. One has maintained the Department of Public Safety licensure, while the other has not kept up with quarterly fire inspections.
Both hospitals are at least a few acres from surrounding residential areas and have no close abutters. There are no abutters that would prevent surge use of the hospitals. One hospital has a nursing home with approximately 200 beds in a separate building on the property while the other has a closed nursing school. These other buildings could house staff or other support services.
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2.3 Structural Components
One hospital and most of the second are in acceptable physical condition for surge use.
Exterior Structural Components
All exterior structural components, including exterior walls, roof, exterior windows, and exterior doors, are sound and in place at both former hospitals with the exception of the roof over one wing of Hospital 1 where there is extensive water damage from a leaking roof. This area is not currently used, and formerly housed the operating rooms and pre- and post-operative areas. Much of the ceiling has come down due to the water damage. This portion of the hospital would not be usable, but the remainder of the building, comprising capacity of more than 150 beds, is in acceptable condition for surge use.
Interior Structural Components
At Hospital 2, all interior structural components, including floors, walls, ceilings, interior windows, and interior doors are in place and in good condition. At Hospital 1, these interior structural components are in place and in good or usable condition with the following exceptions:
- There is significant damage to the ceiling from water leaks in the former operating room area.
- Parts of the building such as the former psychiatric ward are in general disrepair.
- Room doors are missing from a large percentage of former patient rooms currently used as administrative offices.
As stated above, the portion of Hospital 1 with water damage would not be usable for surge use. For surge use, missing patient room doors would need to be replaced for negative pressure or simple isolation rooms and, if needed, for patient privacy.
Elevators at both hospitals are operational with inspection certificates maintained. Two of the four elevators at Hospital 2 are slated for closure to avoid needed costly repairs.
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In general, all needed utility set-ups at both hospitals are operational and adequate for surge use. There is sufficient space at both hospitals for a portable on-site generator, chiller, and boiler if there is a need to bring these in, although it does not appear this would be necessary as back-up systems are in place at both hospitals.
Recommendation: Working utilities, fixtures, and life-safety systems are an absolute prerequisite for a surge facility.
Both hospitals currently receive power from an outside power source, and each has two outside feeds. Both also have operational on-site power plants that could generate electrical power if the facility is separated from the electrical grid or there is grid failure due to the catastrophic event. Back-up power would feed electricity to life safety systems, equipment branch, and critical branch loads during a loss of normal power. One hospital has two back-up generators, each serving different portions of the building, running on #2 fuel oil. The other has three back-up generators, each capable of serving the entire facility, which can run on either natural gas or #2 fuel oil. The hospitals currently store enough back-up fuel oil to run the back-up generators for 24 to 48 hours. The necessary fuel oil for the back-up generators is typically easy to obtain, and getting fuel oil trucked in during surge use would be highly feasible.
These back-up generators can meet all of the electrical capacity needed during medical surge use. Heat could be maintained to both hospitals with the back-up generators but air conditioning could not. Electric closets and wiring are functional and in good condition at both hospitals in all areas deemed usable for surge capacity.
HVAC Automation Systems
One hospital has a Honeywell automation system controlling portions of the building, while the other facility has no automation system. The existing HVAC control system could easily be overridden if needed. Presence or lack of this type of automation system was deemed to have no effect on whether the hospital was suitable for surge use.
Both hospitals have operational heating systems using a combination of steam and hot water heat. Boilers at both hospitals have dual-fuel capability (diesel or natural gas), but there is not a natural gas connection to the boilers at one of the hospitals due to piping restrictions, so fuel oil would need to be used. At the other hospital, use of natural gas would be preferred to preserve fuel oil for the back-up generators. Both hospitals have capacity to provide full heat to functional building areas and enough heat to prevent freeze conditions in nonfunctional building areas.
Air handlers are operational at both hospitals, with fresh air intakes at roof level. It appears that the requirement to have exhaust greater than 25 feet away from air intakes is met at both hospitals.
The chillers are operational at both hospitals, although one of the two chillers at Hospital 1 is not in good shape and would not likely be functional for an extended period of time without significant reconditioning. The chillers cannot function from the back-up generators. It is extremely unlikely that lack of air conditioning would prevent surge use although this issue would have to be closely examined should the surge situation occur in the summer months in a warmer climate.
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2.5 Water and Plumbing
Both facilities have a functional water source and plumbing systems.
Water Source and Back-up
The local Publicly-Owned Treatment Works (POTW) supplies water to both hospitals, with two feeds to each for back up. The domestic water booster pump system is operational at both hospitals. The emergency water supply at each hospital could last 2 to 3 days. If catastrophic events cut off a surge facility from the POTW, water would need to be trucked in.
Each of the hospitals has two operational hot water tanks, but they are not currently operating at full capacity. To prepare for surge use, minor maintenance such as checking of pump seals would need to be conducted, and water in both tanks would need to be fully heated. This would take approximately 2 to 3 days.
Plumbing fixtures, such as toilets, sinks, and piping are in place and in good condition at both hospitals. Toilets have been shut down in some areas and flushometers may need to be replaced in some toilets; valves would need to be opened to return water to the system. To conduct these activities and get all toilets operational would take approximately 3 to 5 days, and sections of the hospitals could be outfitted and reopened in stages.
No on-site waste water treatment is conducted at either hospital. Waste water is returned to the local POTW, and all necessary piping is in place at both hospitals. There are no special waste water controls or containment at existing ordinary community hospitals in the Boston area, so no such systems would be needed for surge use, even in the case of isolation/quarantine.
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2.6 Containment and Wastes
Hospital 1 has a few negative pressure/isolation rooms on almost every floor with HEPA filters. These would need to be re-certified prior to surge use. At Hospital 2, only a very few rooms (perhaps four) were formerly negative pressure and we could not determine whether filters in such rooms are still functional. At both hospitals, the air handling systems are such that entire floors could be converted to negative pressure via manual controls, thus converting an entire floor into an isolation area.
Current requirements indicate that an anteroom (a defined space from which air is being removed) must exist outside of isolation patient rooms. If entire floors are converted to negative pressure, a defined space with doors must be identified to serve as the anteroom for the entire floor.
The function of negative pressure in isolation areas is to ensure that contaminated air does not go elsewhere within the facility via seepage to the air handling system. Systems at ordinary community hospitals, however, including these two assessed hospitals, do not filter or otherwise contain air contaminants from exiting via the exhaust to the outside. For this reason, if an entire hospital is used for the purposes of isolation/quarantine, an assessment would be needed to ensure that contagions cannot enter facility fresh air intakes, drift to receiving areas or entranceways, or migrate to sensitive receptors in the area.
Neither hospital houses an operational on-site incinerator for destruction of medical wastes, nor were there other waste treatment systems on-site. Both hospitals have adequate, separated space near the loading docks to store red-bag (biohazard) waste until pick-up by a licensed hauler.
Both hospitals have compactors and dumpsters on-site for management of solid wastes until pick-up.
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Both hospitals had on-site pharmacies and therefore have a physical set-up for this activity. At Hospital 1, the pharmacy inventory management system is still available in the computer system. For surge use, it would be feasible to create an on-site pharmacy.
Neither hospital has a functioning laboratory. At Hospital 1, only very limited lab work was ever conducted on-site, and all lab equipment has been removed. Hospital 2 has two functional and operating blood draw rooms, bench space, working hoods, and a reverse osmosis water system, but other laboratory equipment has been removed. For surge use, it would be more practicable to send samples out to local medical laboratories rather than try to create or restore functioning labs at the hospitals. Portable lab kits and bedside testing are another option, discussed below.
Both hospitals have morgue cold storage, but at very limited capacity. Hospital 2 has a small refrigerated unit that could hold two bodies and Hospital 1 has a cold room that can hold at most 20 corpses in body bags or only a few on stretchers. Under the first scenario of using the hospital for noncritical medical and surgical patients, this capacity may be adequate. Under the second isolation/quarantine scenario, if there is high mortality from the infectious agent, this capacity will likely be inadequate. In this case, refrigeration trucks could be brought in. Obtaining these refrigeration trucks is readily feasible in Boston or other urban areas.
On-site food preparation capability is not absolutely required for surge use of a facility, but would certainly enhance convenience. Both hospitals have full kitchens and cafeterias. At Hospital 1, the kitchen is currently only used to heat food. Returning this kitchen to full food preparation capability would require re-charging the Ansul fire suppression system over the stove, which would take approximately 3 to 5 days. Hospital 2 has a more fully functional kitchen and is currently operating at full capability as a public cafeteria-style restaurant for local residents.
No laundry service is available on-site at either hospital. Sterilizers exist in both hospitals and appeared functional. In addition, three cart washers are available at Hospital 1. On-site laundry capability is not necessary for surge use of the facilities and could instead be conducted off-site.
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2.8 Patient Care Spaces and Patient Care Needs
Hospital 1 was at one time licensed for 350 beds and Hospital 2 for 161 beds. At Hospital 1, there would be appropriate space for at least 150 beds (some of the space is not currently usable due to water damage and general disrepair). Hospital 2 is fully usable to its previous capacity of 161 beds, as the entire building is in good repair.
At Hospital 1, many of the patient rooms are currently being used as administrative offices. A significant effort would be required to move out the desks, filing cabinets, and other items to free up the patient room spaces. It is estimated that it would take at least 24 hours to conduct this move. It would be feasible to move these items to the portions of the hospital not suitable for surge use (i.e., areas in disrepair) or move it all to temporary off-site storage. In addition, significant cleaning would need to occur prior to bringing in patients.
Both hospitals were designed for and contain primarily single and double patient rooms. Patient rooms are each equipped with bathroom facilities, patient panels, and regular and emergency power outlets. Rooms designed as singles are large enough to fit two patient beds. There are two potential regulatory barriers to use of single rooms for two patients. First, current requirements indicate that there should be one panel per patient bed. While both patients could share medical gases from one patient panel by the use of splitters, this is not allowable under current regulations. Second, regulatory requirements dictating size and space required for hospital patient rooms have not yet been explored. Space and head panel requirements might need to be relaxed in a surge event, or portables could be used for a second patient in a single room.
As the hospitals were generally designed for single and double patient rooms, most of the space does not work well for a multi-patient ward arrangement. There are a few spaces at each hospital that we identified as potentially suitable for a ward in the event that low staffing levels dictate this need. Such spaces include the former post-operative/recovery areas, and the former intensive care and transitional care units, where visual observation of multiple patients by one staff member is possible.
In the standard patient room areas, both hospitals had a pod-type set-up with a nursing station for every 8-12 patient rooms.
The medical gas system that supplies patient rooms is still in place at both hospitals, but would need to be tested and reconditioned with some replacement of parts at outlets. Medical gas outlets are current enough at both hospitals that parts could be obtained. Oxygen hook-ups are compatible with new oxygen machines at both hospitals. Before the medical gas delivery system could be used, the lines would need to be cleaned. The zone valve and alarm panels would need to be verified to service areas. The system would need to be re-certified by a medical gas certification company. At both hospitals, the bulk oxygen supply tank has been removed, but the truck connection exists for delivery from a liquid oxygen tanker truck.
To complete all of the tasks described above and get the medical gas system operational would take a minimum of a week to the first area in each hospital designated to receive patients, with a few weeks needed to bring a whole hospital back to functional status. Portable equipment would need to be used during the interval to provide medical gases.
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2.9 Non-Patient-Care Spaces
Both hospitals have several large spaces available for non-patient-care needs, including cafeterias, an auditorium, a large lobby area, and conference rooms. Necessary space for non-patient-care functions appears to present no issue or barrier for surge use.
Both hospitals had former reception areas that would work well to control access into and out of the building. Both also had former registration spaces that could be readily prepared for patient registration by re-establishing needed information systems. At Hospital 2 this space is not currently in use, while at Hospital 1 this space is currently used as an elder day-care center and would require move-out of some furniture.
Family Waiting Area
Both hospitals have several large spaces that would be suitable as waiting areas if chairs were brought in.
Staff Sleeping Area
Both hospitals have reasonable options available for staff sleeping areas. At Hospital 1, the former psych ward was identified for this use; at Hospital 2 a large public meeting room in the basement area and also the former rehabilitation area were identified as good options for staff sleeping quarters.
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Nurse Call System
Both hospitals have at least partial nurse call systems in place. It would take approximately 1 week to troubleshoot and reactivate these systems. If surge use is initiated before the nurse call systems are fully operational, manual devices such as bells could be used for this function.
Code Call System
It could not be ascertained whether the code call systems are functional, although the system appeared functional in at least some portions of Hospital 2. It would be difficult to repair or install a code call system during the 3 to 7 days allotted for readying a partially-shuttered hospital for surge use. Alternatives for code call such as sirens or silent paging need to be identified as an element of surge use readiness, especially for Scenario 2 (isolation/quarantine) in which sicker patients would be admitted.
Some patient areas of Hospital 2 contain a telemetry system, while none exists at Hospital 1. A telemetry system was not deemed necessary for surge use. The more critical alarms on vital signs monitoring devices are independent of the telemetry system, and, if deemed necessary at the time, a simple remote radio frequency monitoring system could be brought in to individual floors.
A facility-wide paging system is in place at one hospital but not the other. An operational facility-wide paging system was not deemed necessary for surge use as portable pagers could be used if necessary.
The telephone switch was recently upgraded at Hospital 1, but was not considered operational at Hospital 2, where the town has a system and the current outpatient unit has its own switch. While a single functional hospital-wide telephone system would be convenient, lack of such a system is not a barrier to surge use. Many alternate means of communication could be used such as two-way radios or cellular telephones.
Computer Network and Internet
Hospital 1 is wired for IT/network and Internet. There are IT closets on every floor, and IT cables into all patient rooms (other than psychiatric rooms) and nurse stations. At Hospital 2, data sockets exist for network, but it was unknown if they are operational. If a hospital-wide network cannot be established, alternatives are presented in the IT chapter of this document.
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Overall, the experts assessing these two partially-shuttered hospitals agree that they would be good candidates for surge capacity use. The condition of structural components, fixed equipment, and systems was generally good enough that they could be brought to full operational status within the 3 to 7 days before surge capacity use would begin. For items requiring more than 7 days, it appears that feasible temporary options exist. Since these were functional hospitals just a few years ago, design and layout are well suited to the intended medical use during surge capacity.
Table 2 summarizes the status of typical conditions one might expect to find at recently or partially-shuttered hospitals relative to surge capacity use, based on the assessments conducted and expertise of the team.
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2.12 Preparing to Open a Partially-Shuttered Hospital
As discussed above, the physical plants of the partially-shuttered hospitals we assessed are in relatively good structural and operational condition. Below we list items that probably would not require additional attention, and those for which outsourcing might be optimal.
Recommendation: A former hospital has advantages for surge capacity over a school, hotel, or gymnasium, including: patient care and nursing-station lay-out, familiarity for clinical staff, food-prep, morgue, lockable pharmacy space, isolation rooms, and more.
2.12.1 No Additional Attention Required
- Roadway Access and Parking: Ambulance, bus, truck, and car access to the assessed partially-shuttered facilities is feasible and in good condition. Ample on-site parking is available for surge facility use.
- Exterior Structural Components: Exterior structural components, including walls, doors, windows, and roof were intact and in place. Water leaks through the roof did exist in limited facility areas, but it was determined that these areas would simply not be used versus conducting repairs to these areas.
- Interior Structural Components: Excepting limited areas with water damage at one assessed facility, interior structural components including floors, walls, and ceilings were in good condition. Many interior patient room doors are missing at one of the assessed facilities, but it was determined that replacement of these doors was not necessary and would not be conducted.
- Lay-out: Due to previous use as an inpatient hospital, the partially-shuttered hospital facilities have functional spaces to serve as a reception/registration area, patient rooms and wards, nursing stations, a family waiting area, staff sleeping spaces, equipment and supplies storage, and for any other operational needs. Nonfixed items, such as chairs, beds, and medical equipment and supplies, are needed. Procurement of these items is discussed in more detail in Chapter 3, Equipment and Supplies.
- Electric Power: It is expected that functional power supply set-ups, including back-up generators, will be in place at partially-shuttered hospitals, as is the case with the facilities assessed in the Boston area. No additional actions are necessary to ensure power to the surge facility, excepting routine fuel delivery as needed for back-up generators, which will likely not be needed.
- Pharmacy Space: It is expected that usable, lockable areas will exist at partially-shuttered hospitals for set-up of pharmacy services, as is the case with the facilities assessed in the Boston area. Equipment and pharmaceuticals are needed, but space suitable for use as a pharmacy is in place. Procurement of needed pharmacy equipment and pharmaceuticals is discussed in more detail in Chapter 3, Equipment and Supplies.
Other services at the partially-shuttered hospitals are either completely absent or could not easily be brought back into full operation in time for opening of the surge facility. Some of these services can readily be outsourced. Information on making contractual arrangements for these services is given in Chapter 3.
2.12.2 Recommended for Outsourcing
Recommendation: Some services normally provided by hospital staff/equipment should be out-sourced for a temporary surge facility, rather than trying to bring them back to in-house status in a matter of days.
- Laboratory: While spaces formerly used as laboratories will likely exist at partially shuttered hospitals, all equipment will generally be gone, as is the case with the facilities assessed in the Boston area. It is not feasible to procure laboratory equipment and supplies and qualified technicians within the necessary timeframe, nor will it be possible to set up quality procedures and accreditation within 1 week. For these reasons, laboratory services will need to be outsourced at the surge facility.
- Laundry: Laundry machines and set-up will likely not be available at partially shuttered hospitals. Procurement and installation of machines and set-up of operations to meet stringent sanitation requirements such as sterilization will require a significant effort. For these reasons and because of more urgently needed efforts to bring the medical services into readiness, it is recommended that these services be outsourced for the surge facility.
- Food Preparation: Kitchen facilities may or may not be functional. If they are functional, a significant effort likely will be needed to bring stove hood fire suppression systems up to code, as discussed further in Section 3.2.4. Also, the kitchen must be brought up to local and State sanitation code requirements. Further, procurement of food and qualified kitchen staff will be required. For these reasons, and because of more urgent needed efforts to bring the medical services into readiness, it is recommended that food preparation services be outsourced.
Pharmacy, sanitation engineering, and major components of equipment and supplies may also be appropriate for outsourcing.
In addition to facilities and services in place or readily outsourced, certain corrective actions will be needed to bring a partially shuttered hospital into suitable condition for use as a functioning surge hospital. Information on securing needed facility and maintenance staff, equipment, or services for each of these areas is provided below. Subsequent chapters of this report address medical staffing, medical equipment and supplies, and other requirements.
2.12.3 Staffing and Supplies for Needed Facility Upgrades
In order to get a shuttered hospital up and ready, both staff and supplies will be needed and repairs will need to be completed before patients arrive. The facility will need to be emptied of unnecessary furniture and cleaned. This section of the report describes all of the preparatory activities that must be undertaken before the surge facility opens and the staffing and supplies that will be needed to accomplish these activities.
A team of qualified facilities staff will be needed to bring utility systems fully up to operational capacity, and to conduct needed repairs, testing, and general facility readiness activities. At each of the two partially shuttered hospitals assessed in Massachusetts, only one or two facilities personnel currently remain on staff and would not be able to accomplish all these tasks in the 3-7 days before patients need to be transported. A team of approximately 15 facilities personnel would be needed to prepare the surge facility for opening within a one-week period. The majority of these personnel should have an HVAC license. Also, at least two of these staff should be licensed plumbers and at least one or two should be licensed electricians.
Facility operations management from the major Boston tertiary hospitals indicated that they could readily assemble this team from within their own staff, and that they would still have adequate staff to conduct needed activities at their own facility, even during a mass casualty event. While this might be true in Boston, it may not be true elsewhere. In the event that a major hospital cannot provide its own staff for these essential functions, other arrangements must be made. Every major city will have a mechanical temporary agency that could provide the needed facilities staff, probably within a day. It would not be necessary to have advance contractual arrangements with this type of agency. In addition, every city will have a large number of property and facility management companies who also employ facilities staff. Facilities experts indicated that these companies would be willing to serve during an emergency.
Facility Repairs and Supplies
Replacement parts, fixtures, and supplies for minor electrical or plumbing repairs may be needed to prepare the surge facility for opening. Partially shuttered hospitals will have a limited quantity of these supplies in stock. If additional supplies are needed, every major city will have specialty supply houses for the different trades, such as plumbing supply houses used by licensed plumbers. These will typically contain whatever might be needed for the facility preparation. In addition to the supply houses used by the trade, every major city will have large supply outlets used by contractors and homeowners, such as Home Depot, that also contain most of what might be needed for the facility preparation.
Removal of Extraneous Furniture and Items
The assessed facilities in Boston are using patient care spaces for administrative and other nonmedical functions, and this may be equally true at shuttered hospitals in other cities. Prior to opening the surge facility for use as an inpatient hospital, desks, filing cabinets, office equipment, and other furniture or items will need to be removed as quickly as possible, so that the space can be cleaned and made ready for beds and other medical equipment.
Local moving and storage companies could provide enough staff and trucks to conduct this move-out within a day. In particular, moving companies specializing in office moves routinely conduct moves of this scale quickly (often overnight). Moving company officials we contacted indicated that an advance contract would not be required and that they would make every effort to provide assistance during a catastrophic emergency event. If a moving company cannot be obtained, every major city will have temporary agencies that can provide general laborers, and could provide a large crew within a day without the requirement of an advance contract.
The movers or laborers may be able to move unwanted items into other unusable portions of the facility to expedite matters. If items must be fully removed from the hospital, use of moving trucks or truck rental and temporary storage would need to be arranged in conjunction with use of the movers or temporary laborers. Transportation experts indicate that there will be more than enough trucks available for rental in a major city and that an advance contract would not be required.
Any major city will have a variety of cleaning service contractors available that could respond within a day or less to prepare a shuttered facility for patient care. Industrial and commercial cleaning contractors will have staffing, equipment, and cleaning products on-hand to conduct the necessary facility cleaning, and could respond immediately if not fully committed elsewhere. Commercial cleaning company managers we contacted indicated that they maintain, in addition to their regular staff, a roster of extra workers to be called in when there are large or unanticipated jobs. These managers agreed that the needed team of cleaners for the surge facility could be readily assembled with a combination of the regular and occasional staff.
Specialty cleaning contractors also are prepared to respond quickly following emergencies. These firms include disaster cleaning specialists (who clean facilities following fires, floods, and other disasters) and death and crime scene cleaning specialists. This level of expertise is unlikely to be needed, but does exist in any major city. Local hospitals will likely have contracts with such specialty cleaning services and the cleaning of the surge facility could perhaps be arranged under one of these existing contracts. If not, advance contracting with a specialty cleaning firm is not necessary as these firms are organized to respond quickly to unplanned events.
It may be necessary to close off the unusable or unsafe portions of the partially shuttered facility—for example, areas where roof water leaks have caused ceiling damage. For security purposes (go to Chapter 6 for a more detailed discussion of security) it may be advisable to restrict access to certain parts of the surge facility. And some spaces of the facility may be currently in use for other purposes and will need to be physically separated from the inpatient facility. One straightforward method to accomplish this is to erect walls or barriers at key access points. Staff from the facilities team or general laborers hired to conduct the move-out could readily accomplish this partitioning using plywood or other building materials. Note that, in areas where physical partitioning is not feasible, security staff or security monitoring equipment can be used, as discussed further below.
Both Massachusetts facilities we assessed have operational elevators with current inspection certificates. For partially shuttered hospitals with any activities occurring on upper floors, this would be expected. In the event that a shuttered facility has not maintained inspection certificates for their elevators, local elevator companies can arrange for an inspector; in an emergency, these inspections should be possible within a day or 2.
Life Safety Systems
Partially shuttered hospitals are likely to have functional sprinkler and fire alarm systems in place, as is the case with the assessed facilities in Massachusetts. If the facility has not maintained licensure with the local Department of Public Safety, a fire inspection will need to occur prior to opening the surge facility. Local fire department officials indicated that they could conduct this inspection within the 3 to 7 days prior to opening of the surge facility, and this would also be expected in other localities.
In the event that a facility does not have functional sprinkler systems in place, it can still be opened as a surge facility. Portable fire extinguishers would be required and the facility must be kept under an around-the-clock fire watch by the fire department. Fire safety suppliers indicated that there is a more than ample supply of portable extinguishers always on-hand to fully outfit a surge facility (hundreds of portable extinguishers are typically in stock). Additionally, fire safety suppliers indicated that they could readily provide the Occupational Safety and Health Administration (OSHA)-required fire extinguisher training (approximately 1 hour in length) to surge facility staff within the 3 to 7 day timeframe. The fire watch would be staffed by the local fire department on all shifts. Based on standard mutual aid agreements that exist between local fire departments, fire companies from other municipalities could conduct the fire watch if the local fire department is not available for this function.
Partially shuttered hospitals will typically have functional HVAC systems. Facilities staff with HVAC licenses will need to test the HVAC system prior to opening of the surge facility. This will include an area-by-area inspection and any needed system adjustments, as well as returning full levels of heat or air conditioning to all building areas that will be used. In addition, under Scenario 2, some floors may need to be converted to negative pressure through manual override of HVAC controls, and isolation rooms may need to be re-certified. All of this HVAC work could occur within a week.
Plumbing and Hot Water
As with the facilities assessed in the Boston area, it is expected that partially shuttered hospitals will have functional plumbing and hot water systems. Facilities staff, including some licensed plumbers will need to conduct work prior to opening of the surge facility. This will include opening valves to return water to all building areas that will be used, and replacing minor parts on sinks and toilets as needed. Also, for hot water, minor maintenance such as checking of pump seals must be undertaken, as well as initiating full heating of hot water tanks. With the staffing level described in Section 3.1, all of this plumbing work could occur within a week.
Partially shuttered facilities will typically have centralized medical gas delivery systems with patient room wall outlets, and the bulk oxygen tanks for these systems will likely have been removed, as was the case with the facilities assessed in Massachusetts. It may or may not be feasible to return these systems to operational status, depending on how the system was closed down. If the lines were not valved off and capped when the bulk oxygen tank was removed, and back bodies were not installed at wall outlets, the system pipelines may have become oxidized or otherwise contaminated.
A credentialed medical gas system verifier is needed to check the status of the medical gas delivery system. The system verifier will inspect the entire system and test the lines by introducing nitrogen into each pipeline and testing for purity by looking for hydrocarbons or particulates. If pipelines are usable or can be made usable through cleaning, the medical gas delivery system could be brought back online. In addition to the piping, zone valve and alarm panels must be verified, and wall outlets must be tested. Credentialed technicians are typically readily available for immediate response, and these medical gas system verifiers can be located at http://www.mgpho.org by State.
Parts for wall outlets can typically be shipped overnight anywhere in the country, and in the worst case obtaining these parts would take only days. Repair parts for the central system can be obtained within a week. Items requiring full replacement, such as manifolds, will take 3 to 4 weeks to obtain. Medical vacuum systems (to provide suction) could take months to obtain. Advance contracts would not be necessary as these suppliers will do emergency credit card orders, but obtaining parts may cause substantial delays.
Medical gas supply companies indicated that bulk oxygen trucks are always available and could be at the surge facility within 2 hours to supply oxygen to a centralized medical gas system. These companies indicated that a contract would need to be set up in advance for this service. The truck connection for the oxygen was still in place at both assessed facilities.
If the in-house system cannot be brought back online in a timely fashion, portable medical gases could be used instead. We contacted several medical gas supply companies and each indicated that they maintain a large stock of portable oxygen cylinders, and could realistically provide a more than adequate supply for continued operation of a 200-300 bed surge facility for weeks or months. Another supplier would be needed for the masks and regulators used in conjunction with the oxygen cylinders, and suppliers of these items indicated that masks and regulators could be shipped within a day or 2; in addition, these suppliers indicated that they each typically have double or triple the needed quantity in stock. Portable suction devices are also readily available.
In addition to the medical gas suppliers that service hospitals, durable medical equipment companies also service medical supply needs to home patients. Portable oxygen is a major component of the service of these companies, thus they maintain large stocks. These companies are set up to respond quickly to these supply delivery needs, and they maintain large fleets of drivers and delivery vehicles.
Limited refrigerated morgue space is available at the partially shuttered facilities we assessed. The available morgue space might be sufficient for Scenario 1, when mortality would be low as patients would be noncritical/ambulatory medical and surgical patients. Under Scenario 2, however, if the infectious agent has a high mortality rate, additional refrigerated morgue space may be needed. Physicians who are expert in mass casualty situations recommended use of refrigerated trucks for supplemental morgue space at the surge facility. The National Association of Medical Examiners Mass Fatality Plan also recommends the use of refrigerated trucks. Refrigerated trucks with metal floors and ramps that allow for decontamination are recommended, and 20 bodies can be stored per 40-foot trailer maintained at 35-38 degrees Fahrenheit.
Based on these medical examiner recommendations, likely one and at most a few trucks would be needed to supplement morgue space. In addition, medical examiners in major cities will likely have refrigerated trucks. If the medical examiner cannot provide a refrigerated truck, very large fleets of refrigerated trucks exist in a major city. For example, 2002 economic census data showed 1,600 refrigerated tractor trucks and 3,600 refrigerated vans in Massachusetts. Options for obtaining refrigerated trucks including rental, leasing, or borrowing. Large truck leasing companies such as Ryder and Penske have refrigerated trucks available for rental. There are additional refrigerated storage options beyond the use of trucks. In assessing the Boston area, a few specialty firms were located that focus solely on rental of refrigerated storage units, including delivery of large walk-in refrigerated storage units, and refrigerated trailers (that can be moved via a pick-up with a trailer hitch). In extreme situations, truck purchase could also be considered.
Kitchen Fire Suppression
Partially shuttered hospitals may not have functional food preparation kitchens in place. Even potentially functional kitchens may not be usable for food preparation for the surge facility if the fire suppression equipment is not up to code. Kitchen stoves must have stove hood fire suppression systems in place. These systems were previously charged with dry chemical, but in 1998 the requirements changed to a wet chemical system. Many facilities were grandfathered, so partially shuttered hospitals are likely to have the older systems, which are probably no longer functional. Recharging of stoves with the older system is not possible as powder and parts are no longer available. To install a new system is a complex matter, requiring an electrician because the wet chemical system is electrically conductive, a plumber to ensure that the gas valve is compatible with the fire system, and a fire alarm company technician because the fire suppression system will be tied in with the facility fire alarm. This could be accomplished within the 7 days before surge facility opening, but may not be worth the effort as food preparation services can be readily outsourced.
Partially shuttered hospitals will likely have a wide variability in the types and status of communications systems. At the two facilities we assessed, one had a telephone switch, and one did not; one had a facility-wide paging system, and one did not; one was wired for a LAN network and the Internet, and the other was not. Where fixed communications systems do not exist or cannot be made functional quickly, portable alternatives can be used to meet the communication needs.
Some method for a nurse call and code call system will be needed for a surge facility. Infrastructure for these systems will likely be in place at partially shuttered hospitals, but they may not be operational. Facilities experts indicated that these systems could likely be repaired and reactivated within a week. If they cannot be repaired or do not exist, patient rooms could be equipped with portable hand bells to serve as a nurse call system. Fixed bells mounted outside of patient rooms and struck to alert other staff to a code situation could serve as the code call system. Although rudimentary, such a system may suffice for the few weeks during which a facility operates under Scenario 1; such a system may be less adequate, however, for several months of operation under Scenario 2.
Medical experts advise that facility-wide paging systems and telemetry are not necessary for a functional surge hospital, so these systems do not need to be repaired or replaced with portables.
There will be many needs surrounding internal and external communications, including security, patient information, logistics, and staff coordination on patient care. These activities would be conducted via telephone or computer under normal circumstances of operation. During the facility inspection, the team should note the presence or absence of information technology and consider several options:
- Any existing network infrastructure.
- Analog phone/fax service with no data access.
- Analog phone/fax service with limited dial-up.
Recommendation: Internal and external communications will require an off-the-shelf solution, as the former hospital's systems and equipment will not be intact.
If traditional telephone lines are available, dial-up Internet access may be an option. There are many acceptable options to choose from in major metropolitan areas, including both national and local providers. In some hospitals that have recently been closed, the telephone lines may actually be digital—which would not allow analog communication, making dial-up impossible. Likewise older, degraded analog lines may not provide acceptable speeds—despite an ISP's ability to deliver 56k. Even at 56k, with the large file sizes and complex Web-based applications widely used today in hospital operations, dial-up connections would provide only a very basic and limited connection with external data systems.
For basic Internet and voice communication, planners may wish to disregard available data ports and telephone lines, which may be obsolete or damaged, and institute a completely wireless system.18 Assuming a clear view of the southern sky, vendors can install a satellite Internet connection, and wireless area network protocol. This will provide wireless Internet access in select portions of the hospital. It would not provide Internet connections across the facility. If other portions of the surge facility currently operate as office space, and internet connections are live, the IT and facility planners may elect to install wireless routers that could provide internet connectivity wirelessly to other portions of the hospital, making the satellite unnecessary.
There is lingering concern, however, over the safety of wireless networks/devices on patients with pacemakers, and their effect on advanced medical devices such as MRIs. Several studies suggest that there is little if any impact. A study conducted by wireless vendors Linksys and Cisco suggests that wireless frequencies operating even in close proximity produce no effect on most medical devices.19 Despite these studies and increased use of new wireless technologies in medical environments (i.e., RFID), many continue to question their appropriateness in medical settings, and do ban the use in some areas—including operating rooms.
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