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COVID-19


Never in modern life had we been challenged with an infectious disease of such epidemic proportions where healthcare facilities had to provide urgent medical care to excessive numbers of patients


resources and supporting infrastructure.11 Due to infrastructure limitations and the enormous demand, oxygen was in short supply and innovative solutions were found to ensure a continuous oxygen supply, especially in triage areas. Centralised piped oxygen systems, fed by a large liquid oxygen tank or cylinders, were used in areas where it was available.11


It was,


however, not necessarily available in all triage areas and oxygen cylinders had to be replaced frequently due to the high oxygen demand. The solution was to use


transmission is only required where aerosolisation of particles may be a risk due to AGP.11,12 Increased air changes are


necessary to ensure adequate dilution of contaminated air and to achieve 12 ACH in areas where AGP are performed and 6 ACH in other areas where COVID-19 patients are accommodated.10,13


Existing Figure 6. Extractor fans.


oxygen concentrators, which purify oxygen (>90 per cent) from ambient air through nitrogen-absorbing zeolite membranes.11


This was a cost-effective


and scalable way to supply oxygen, but maintenance and regular servicing was essential to ensure that the concentrators remained fully functional. A reliable power supply was needed which was a challenge in a country where the national electricity supply was continuously and sometimes, unannounced, interrupted and healthcare facilities had to rely on stand-by generators.10 It was a valuable alternative resource to supplement the oxygen demand, despite the disadvantage of insufficient levels of oxygen flow for patients with severe hypoxia and leakage from ill-fitting adapters. Ill-fitting adapters could lead to insufficient levels of oxygen flow and could cause up to 70 per cent loss of the cylinder content, too much for a critical and scare resource.10


Oxygen consumption


levels were continuously monitored and an alarm system was triggered when the supplies reached a pre-determined minimum level.


Ventilation While SARS-CoV-2 ribonucleic acid (RNA) has been detected in ventilation systems, there is currently no proof of viability of the virus and no evidence of transmission through the ventilation system.11


The virus


primarily spreads through droplet and contact and is not considered airborne. Respiratory protection against airborne


IFHE DIGEST 2022


ventilation systems had to be modified to adhere to these requirements. Fans and extractors were used to extract air through custom made openings in windows to ensure adequate airflow and pressure regimes (see Fig 6).


However, the most cost-effective and non-invasive way of achieving these standards was to open windows. Opening of windows improved natural ventilation effectively and could be adjusted according to ambient conditions. Mechanical systems were set to maximise fresh air supply and no air was recirculated without HEPA filtration.10 Where windows were opened to


increase natural ventilation, concerns were raised about the airflow direction between naturally ventilated zones due to fluctuation in the wind direction. This was, however, less of a concern within and between isolation zones where occupants were either protected with mandatory PPE or confirmed to be infected with SARS-CoV-2. Where there was a concern of backflow of air into areas accommodating non-infectious patients, natural ventilation was not an option.10


Conclusion


It is important that the lessons that were learned during the pandemic are applied for the design of future healthcare facilities. Provision must be made for adequate ventilation requirements, adequate oxygen and isolation facilities. This is particularly important in a


country such as South Africa with a high burden of pulmonary tuberculosis and other infectious diseases. It is imperative that IPC teams and hospital engineers work closely together to ensure safer healthcare facilities for both patients and healthcare workers alike.


References 1 World Health Organisation. Emergency triage assessment and treatment (ETAT): A manual for participants [https://apps.who.int/ iris/bitstream/handle/10665/43386/ 9241546875_eng.pdf?sequence=1. 2005].


2 Morrow BM, Gopalan PD, Joubert I, Paruk F, Pope A. Critical care triage during the COVID-19 pandemic in South Africa: A constitutional imperative. S Afr Med J 2020; 110 (12): 1176-9 [https://doi.org/10.7196/ SAMJ.2020.v110i12.15411].


3 National Institute for Communicable Diseases. Coronavirus disease 2019 (COVID-19) Guidelines for case-finding, diagnosis, and public health response in South Africa (version 3.2), 12 July 2020 [https://www.nicd.ac.za/wp-content/ uploads/2020/07/NICD_DoH-COVID-19- Guidelines_Final_3-Jul-2020.pdf].


4 Africa CDC and ICAN webinar series. Williams N, Mehtar S. Optimizing the environment for IPC: Screening and Triage for C19 and Ebola and COVID-19 IPC Measures. 17 April 2021.


5 South African National Department of Health. COVID-19 Disease: Infection Prevention and Control Guidelines (version 2), May 2020 [https://www.nicd.ac.za/wp-content/ uploads/ 2020/05/ipc-guidelines-covid-19- version-2-21-may-2020.pdf].


6 Mediclinic Southern Africa. Infrastructure Brief, 17 April 2020.


7 Stein F, Perry M, Banda G, Woolhouse M, Mutapi F. Oxygen provision to fight COVID-19 in sub-Saharan Africa. BMJ Glob Health 2020; 5 (6): e002786.


8 Davies M, Furneaux R. Bureau of Investigative Journalism. 25 May 2021 [https://www.statista.com/ chart/24989/ medical-oxygen-demand- increase-by-country].


9 Seleka N. News24. Durban hospital hit by 6 deaths after ‘oxygen supply interruption’, probe launched. 7 January 2021 [https://www.news24.com/news24/ southafrica/news/durban-hospital-hit-by-6- deaths-after-oxygen-supply-interruption- probe-launched-20210107].


10 Hillside. Infrastructure Guidance for COVID-19/ Alternative Care Sites [https://thehillside.info/ index.php/Infrastructure_Guidance_for_ COVID-19/Alternate_Care_Sites].


11 Dondorp AJ, Hayat M, Aryal D, Beane A, Schultz MJ. Respiratory Support in COVID-19 Patients, with a Focus on Resource-Limited Settings,. Am J Trop Med Hyg 2020; 102 (6): 1191-7. doi:10.4269/ajtmh.20-0283.


12 European Centre for Disease Prevention and Control. Heating, ventilation and air- conditioning systems in die context of COVID-19, 11 November 2020 [https://www.ecdc.europa.eu/sites/default/ files/documents/Heating-ventilation-air- conditioning-systems-in-the-context-of- COVID-19-first-update.pdf].


IFHE


13 World Health Organization. Coronavirus disease (COVID-19): How is it transmitted? 13 December 2020 [https://www.who.int/ news-room/q-a-detail/coronavirus-disease- covid-19-how-is-it-transmitted].


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