While the flu is something that long-term care providers deal with every year, the industry wasn’t prepared for a crisis of the magnitude of COVID-19. Even if a vaccine is developed quickly, viruses of this nature will be something that the senior living industry needs to be prepared for in years to come.
Innovative infection control design practices will be more critical than ever in our senior living communities. One of the most important issues will be addressing how to isolate residents with COVID-19 and protect other residents and staff.
Room selection
There are several considerations for selecting rooms to designate for residents with COVID-19, including private rooms with private baths (including a shower), rooms with good exhaust and mechanically supplied fresh air, and the ability to modify them to create an anteroom.
Another strategy is selecting a group of rooms that can be isolated from other parts of the community to create a segregated infection unit. Specifically, choose rooms that are not on the main circulation path, such as at an end of a corridor, to reduce people passing by and risking infection. The small house model is ideal for this situation as one entire household can be designated for isolation.
Whether selecting a dedicated household or group of rooms, an anteroom should be created at the entry point with handwashing sinks to support infection control measures and adequate space for donning and doffing of personal protective equipment (PPE) by staff. Closing cross-corridor doors and erecting temporary partitions can separate this anteroom from clean areas. An alternate is to create an anteroom inside each resident room. For example, if access to the toilet room is not accessed through the vestibule area, a plastic partition can create a barrier between the foyer space and the main room to serve as the anteroom.
Mechanical systems
While the industry is still learning more about how COVID-19 is transmitted, it’s understood for now that it’s primarily spread through airborne droplets. This means that a community’s HVAC system moves from being a supporting cast member to star of the show in addressing infection control.
Creating negative air pressure in resident rooms is key so that more air is being exhausted from the room than is being supplied. This prevents “infected” air from going out into the corridor or other spaces. Typically, exhaust fans, which can help move air, are located only in the bathroom but could be added near the resident bed to increase exhaust rates and create negative pressure.
Another factor in the HVAC system is bringing in fresh outdoor air instead of recirculating the same air (referred to as “air changes” and measured in the number of times the air is replaced every hour). Typical nursing rooms have two air changes per hour. However, airborne isolation rooms should have six to 12 air changes per hour to dilute contaminants in the air, making it safer for care staff.
Additional exhaust fan units can be added to the room to improve the volume of air and increase negative pressure. This can be a permanent measure by adding ducting above the ceiling, directly through an outside wall, or a temporary solution by adding a duct through a window opening block-out.
When locating additional exhaust units, it’s best to draw the air away from the infected resident as quickly as possible and draw fresh air from the entry area of the room. This reduces the likelihood of contaminated air migrating into the corridor and the rest of the building. Also, make sure that exhaust discharge points are located far enough away from any fresh air intakes, doors, and operable windows to prevent contaminated air from re-entering the building.
Most modern skilled nursing buildings have a dedicated outdoor air system pumping fresh, conditioned air directly into each resident room. Ideally, this fresh air should be ducted into the vestibule of the room, which will help with the air flow direction described above. However, older buildings and many assisted living buildings built before 2015 don’t have a dedicated fresh air system and rely on ventilation from windows only.
Specifically, those with recirculating-type HVAC units such as through-the-wall package units, water source heat pumps, and fan coil units often don’t have a fresh air source. Contaminants may collect on the filter and internal parts of these units, resulting in contaminated air recirculated through the room. The best option in a temporary situation is to replace the air filter with the highest filtration capacity that the unit can support, change filters more often, and disinfect the unit frequently.
For resident rooms that have a minimal number of air changes and can’t add exhaust air, a portable recirculating HEPA filter unit might be an alternative. If sized properly, these units can circulate the equivalent of 12 air changes per hour, while higher quality units also incorporate internal UV-C lighting that can kill bacteria that comes through the system. Bi-polar ionization devices are showing great promise in neutralizing contagions in the air as well as reducing dust, mold, and odors. These devices can kill virus particles both in the air and on surfaces in a room and can be retrofitted into existing systems, including packaged terminal air conditioner units.
Future focus
These recommendations are meant to temporarily improve existing buildings to better protect residents and staff. However, with new construction and future renovation projects, building in these features from the start would go a long way toward providing safer and healthier environments, both now and in the years to come.
Amy Carpenter is a principal at SFCS Architects (Blue Bell, Pa.). She can be reached at [email protected]. Vernon Feather is a managing principal for SFCS Architects (Blue Bell). He can be reached at [email protected]. Tye Campbell is principal emeritus for SFCS Architects (Roanoke, Va.). He can be reached at [email protected]. Stephen Cates is a senior associate at SFCS Architects (Roanoke). He can be reached at [email protected].
