AS A CHILD, many of us will remember our mother chiding us to go out and get some fresh air because it was good for us. While this was often partly because of her need to get on uninterrupted with what she was doing, she was right.
Fresh air is that which is diluted rapidly of existing particles, droplets, etc., due to regular air changes, especially brought about by wind or breezes outdoors.
We all recall from pre-Covid-19 days being in a stuffy room at a meeting with many people present for long periods. Unless it was a warm day, the windows and doors were often closed, and we often wished to leave as soon as possible, and get some fresh air.
The importance of fresh air, and frequent air changes, have also become especially relevant during the Covid-19 pandemic, including in hospitals.
Hospital ventilation
Most clinical areas in acute hospitals are naturally ventilated, i.e. via doors and windows. That has generally been considered adequate and helps contain overall healthcare costs in terms of construction, maintenance and energy.
Exceptions include the operating theatre where ventilation is used to prevent wound infection from bacteria shed by staff during surgery, specialised areas such as the pharmacy and laboratories, and some designated air-controlled rooms (ACR) in clinical areas or wards.
Naturally ventilated single rooms achieved through doors and windows are currently used for patients at greater risk of infection, such as those on anti-cancer chemotherapy, or patients who pose a risk to other patients, like those with MRSA.
However, ACR is required for patients with more highly transmissible infections like measles, and for the more severely immunocompromised patients like those with extensive severe burns and stem cell transplantation.
In Ireland, our publicly funded hospitals have too few single rooms, most of which are naturally ventilated. There is ongoing controversy on whether Covid-19 is spread by both droplets (larger particles) and or aerosols (smaller droplets), with aerosols resulting in wider transmission.
In practice, the spread of SARS-CoV-2 is probably multi-factorial and influenced by how many viral particles the infected person is shedding (greater early on in the disease), air flows, temperature differentials, any procedures that increase the risk of aerosol generation such as bronchoscopy, and other factors.
Droplets vs aerosols
While it may be an over-simplification, the practice has been to recommend ACR for any patient with an infection spread by aerosols like measles, and a naturally ventilated room for a patient with an infection spread by droplets, such as influenza.
Even if the spread of Covid-19 is mainly through droplets in most circumstances, isolation facilities in our hospitals, including all single rooms and designated Covid-19 wards, have been inadequate.
Many hospitals, other healthcare facilities, and workplaces have responded to the challenges presented by Covid-19 by where possible opening doors and windows to increase airflows and with other measures such as social distancing.
However, there are limitations to this given patient and staff comfort in the face of cold temperatures and rain. Portable air-ventilated or air purification systems and monitoring carbon dioxide to indicate when windows and doors should be open are potential solutions, but these present logistical challenges and have to be funded.
We must learn the lessons from the pandemic in terms of how and where we house hospital patients. Many of our existing hospital in-patient facilities were built many years ago and are too small and overcrowded, and the pandemic has highlighted how truly inadequate they are.
This has caused stress to healthcare staff when trying to care for patients in difficult circumstances. Nearly all agree that we need more acute hospital beds, and we must move to single room occupancy with far more space throughout our hospitals. Too many of our hospitals are cluttered and cramped.
Impacts on staff
This has made it challenging for healthcare staff to practice social distancing, because of narrow corridors, small poorly ventilated rooms, and low ceilings. Patients on multi-bed wards have been too close together, hampering efforts to keep clinical areas clean and tidy and thus facilitating the spread of Covid-19 and other infections.
While the pandemic has resulted in many calls on public funds, we must learn the recent lessons and not miss this opportunity to get it right by addressing current and future needs.
As we strive to implement Sláintecare and improve our health service, our hospitals must have more space, with patients being in single rooms, and with more ACR. Furthermore, we must give greater thought to the design of our hospitals, and how we ventilate them.
This will prevent many other infections with the consequences of reduced healthcare costs, less patient suffering, and fewer deaths. It will also greatly help us in coping better with any future pandemic.
A greater number of single rooms will also improve the hospital experience of patients through the provision of greater privacy and dignity, when acutely unwell or especially even dying. This is all largely common sense and our mothers would certainly approve.
Hilary Humphreys is Emeritus Professor of Clinical Microbiology, the Royal College of Surgeons in Ireland.
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