Pressure’s on to Build Negative Pressure Facilities

When it comes to infection control and prevention, especially in light of what we’ve learned during the coronavirus disease 2019 (COVID-19) pandemic, it’s best to get everybody involved, not just infection preventionists. Cedric Steiner, a licensed nursing home administrator, takes that even further: The entire building needs to be involved. He’s not talking about everybody who works in a hospital or long-term care facility, but the buildings themselves. “We have these aged facilities, right?” he tells Infection Control Today®. “But we know we need a better facility, a facility that’s capable of responding with the most basic of infection control, which is negative air pressure.” Computer technology will allow health care facilities to switch entire wings into negative pressure areas with just the flip of a switch. And, for long-term care facilities, the money’s there to make that conversion, Steiner argues. They pocketed a lot of taxpayer money under the Paycheck Protection Program and, in addition, residents at these facilities are mostly covered by Medicare, which also pays well. As Steiner puts it “that’s a significant amount of money.”

Infection Control Today®: When you were researching your article for Infection Control Today® did you find anything that surprised you? Or did it just reinforce what you already knew?

Cedric Steiner: I was surprised at the success of those organizations, particularly Children's Hospital Philadelphia, when they had prepared for a pandemic with using the facility. The premise was looking at it from an infection control point of view—the actual facility. What can we use? What can the facility do for us? And organizations that had invested in building management systems, I think were highly successful. In our discussion with [CHOP’s Senior Director of Building Systems, Operations and Refrigeration] Rachel McCarthy at Children's Hospital of Philadelphia they told me that they had planned, and they had seen it coming. And I believe she mentioned at the time that they were more concerned about, well, there were several of them that came in … you remember SARS, but hemorrhagic fever or Ebola, I think was a big one that really kicked them off. And so, they saw that they needed more negative pressure rooms, and they looked to just broaden it to the whole facility. So a building management system is a system where it’s centrally controlled, and you can…. It’s not individual rooms. It’s the whole units, and she had described several floors with a flip of a switch that can be turned over. Of course, it needs to be monitored those first couple days, but it was turned over rather quickly in that whole area then became AIIR [Airborne Infection Isolation Room]. An area where you could protect your employees and your healthcare workers and the residents. My side would be the nursing home side. It’s a reflection of the hospital. The nursing homes were designed after hospital models. So, they were they were overflow. In the 1950s, there was an act—[Hill-Burton Free and Reduced-Cost Health Care Act]. It gave loans and money to facilities to try to…. It was originally for hospitals, and then it went into nursing homes. So, they have similar models. Talking from a nursing home side of things, thinking retrospectively of what happened in hospitals, I think they’re going to have to do it—and I actually I think nursing homes are going to have to do it. Because we look at the pandemic. I mean, back in Washington State, you look at where it all started. At that nursing home there in Washington County, Washington. And if you look at that facility, it just tore through that facility tremendously. In my article, I led with a hospital up in New England that saw it coming and that was their response. I mean, the first thing that they decided to do was put in a negative pressure floor. So, I can’t imagine that they’re not going to see that as one of the first things that they want to do with their infrastructure. And I mentioned that bill in the 1950s because that was the last time a lot of money went into hospitals. If you think back to 1950 and the money that hospitals used to build, they weren’t thinking about these kinds of things. A lot of the infrastructure is outdated. And you can see that with that hospital, for example, that I mentioned in the article that converted [a floor] into a negative pressure floor. They had to do it on the fly. And they were very out front about doing it. And they were kind of advertising that they had done it. I can’t imagine that that wouldn’t be a focus going forward.

ICT®: Who’s going to make negative pressure rooms work?

Steiner: It’s going to be your building management, environmental services directors. And that’s the situation in some hospitals, I think, is that they’re actively involved, but they’re going to take a more active approach. And on top of that, you’re going to have to bring in as, as one of the gentlemen I interviewed Nick Clements says, you’re going to have to bring in IT services. Because really, where the system is heading is a building management system; it is a computerized building. So outside of the mechanicals, you’re going have your infection preventionist, and then you’re going to have the facilities manager, the people that can manage HVAC systems. They’re professional engineers. And then you’re going to have programmers. You’re going to bring in…. It’s the computer age. You’re going to bring in an IT specialist who makes sure these programs are written. Either that or they’re going to have to be out on the cloud, and as a hospital, you’re going to be contracting with somebody off-site to make sure that this is all functioning. I see that there’s going to be three parts here. You’re going to have the infection preventionists, the medical prevention team, the facilities prevention team, and then they’re going to have an IT component to that either on-site or off-site.

ICT®: Will this happen first in hospitals?

Steiner: Nursing homes were designed as hospital models to take off of the hospital those residents so that they wouldn’t be so high cost in the hospital. They’re kind of like little mini-hospitals almost, in a way. Your question is really good, because you asked me about the hospital, and I’m starting with the nursing homes. But you’re dead on, it’s got to start in the hospitals. But the nursing homes are going to have to do the same thing. In fact, there might be more of a vulnerability in the nursing homes then there is in the hospital. Particularly with COVID-19. We’re looking at age, population. The hospital is pretty transient. But the nursing home…. One could make an argument that it’s more important there in some ways, because have you those residents in smaller spaces. You have a lot of visitors coming in and out. You have health care workers, and one of the problems is sharing of health care workers. A lot more sharing of health care workers happens in nursing homes then it does in hospitals. Where does it fall first? You’re probably right. It’ll go to the hospitals first, and then they’ll act as models. And then the nursing homes will have to pick up on that. And like I wrote, I think that’s already happening. And that facility [in Lancaster County, Pennsylvania], they’ve treated 100. Last time I checked recently, there were 100 residents that they had moved through that negative pressure space. It was only 13 beds, but it gave them the ability to treat and keep the virus confined to that area of the nursing home. And health care workers didn’t…. When we published they didn’t have any cases of health care workers getting the virus in that facility. So, 100 residents. And that was in what would be a rehab facility. And so, when you talk about how the financials work with nursing homes, those 100 patients where it would be paid by Medicare. They were well paying residents for the facility. It worked out very well for them in that they could bill infection isolation and get Medicare reimbursement. I think that there’s a need here in the nursing home. What I’m working on right now is working with building management systems to try to deliver a product to nursing homes so that they could have these zones that they could turn on with a switch, much like the hospitals. I think that’s where we’re going to have to go. Either that or the whole model of nursing care and nursing home care is going to change.

ICT®:We may have to follow the money?

Steiner: The model that we’re currently using: The only way you can get reimbursed or use Medicaid money really is if you go to a nursing home. Most state laws and most federal laws don’t allow Medicaid money to be used at home. If you want to stay at home, you couldn’t use that. I think there are some waivers, but usually you have to go to nursing homes. Well, you go to the nursing home, but that creates an infection control issue. Everybody’s supposed to be isolated, right? We were all supposed to stay at our homes, but instead you had to go to the nursing home or you you’re putting these individuals in nursing homes. And so, we have this problem. And then there’s the funding issue. The nursing homes were able to get PPP [Paycheck Protection Program] money. I want you to think about it. They were able to get two and a half months of expenditures. Just a straight check, basically, to keep the lights on. That’s just you filed your expenditures, and the government wrote you a check for that money. It’s millions of dollars. A 100-bed facility probably is going to get like somewhere of upwards of $1.2 million to $2 million. And what do you do with that money? And the government said, “Well, it’s forgivable as long as you use it for PPE, utilities, and things like that.” One of the questions in the latest AARP magazine was where’s that money? What did they do with that money? Did they just spend it on testing? Did they spend it on employees? Staffing was a big issue. That was a legitimate issue: increasing staffing and pay. But how to account for that. If the long-term care industry decides that they’re going to pocket some of that money? I think that’s going hurt. It hurts them in the long run. I think the numbers are somewhere over 20% or 30% nonprofit and the other 70% or 80% is for profit. If you have some sort of public backlash with the taxpayer giving this large check to nursing homes, and they’re going to put it in their pocket and not go after infection control—what we’re talking about here—that, to me, is going to be…. Somebody is going to uncover that. I think the AARP is already going after it in their articles. So that’s a big issue. And I think that the hospitals will just defer it to the nursing homes, but I don’t see how they can. If the nursing homes do negative pressure or invest in their buildings, the hospitals surely do too. Which is going to come first, the hospitals or the nursing homes? That’s a great question you asked. I predicted nursing homes, you think,

ICT®: I predict the nursing homes.

Steiner: You think so? That would be exciting, wouldn’t it?

ICT®: Because as you said, they have a bucket full of money. They were the hotspots really of the COVID-19 infection. And there are definitely infection prevention problems at nursing homes. Most nursing homes do not have infection preventionists on staff for one thing. Some of that money can be paid to hire a full-time infection preventionist. And also, to convert some of those wings into negative pressure areas. That’s my take.

Steiner: That’s my take as well and I’m out there talking to building management, systems providers. The technology’s there. As you go into Lowe’s or Home Depot, you have people hooking up their houses with their doorbells, video cameras and other things. And it’s when we’re talking about a building management system, we’re talking about card swiping. You can track medications. And running the HVAC system, and the air around the facility. It’s a whole bunch of pieces that all come together under that one network to really make your building a living component to your infection control. No more of this static building space. It needs to get involved with how you’re going to respond. And to those people who are infection preventionists out there—your audience—this is something that they need to look at. They need to really look at, “Hey, who else can help me out in my infection prevention.” In a nursing home, and I’m sure many of your readers know this, when influenza comes in, they start shutting the doors. First thing they do. So, of course, it’s in the back of their mind, but it needs to come to the forefront. I think it would be highly successful in it. You know, for the organization that I was at, I did some calculations on the number of residents that they had in the COVID wing and what those would be paying and that’s a significant amount of money. I mean, it replaced their rehab, when the rehab wasn’t available. As you know, many hospitals were no longer doing knee surgeries and that type of elective stuff. We have these aged facilities, right? But we know we need a better facility, a facility that’s capable of responding with the most basic of infection control, which is negative air pressure. And we know we need to get there like that hospital did and many hospitals around the world responded similarly.

This interview has been edited for clarity and length.