The impact of last summer’s bushfires that burnt an estimated 18.6 million hectares, destroyed almost 6,000 buildings and killed many people and animals was unprecedented, and included a severe drop in air quality caused by the smoke, presenting a further health risk. But what happens when a hospital falls victim to the flames?
When the Centre Hopital Universitaire Point-a-Pitre (CHU) in Guadeloupe experienced a catastrophic fire on 21st November 2017, the surrounding patient community was left with no access to surgical services or to a functioning Emergency and Trauma department. Guadeloupe, which is a French overseas territory, is home to around 450,000 people. The 881-bed hospital is one of the major acute service providers in the region; it carries out approximately 60% of care activity in the archipelago and is one of the few hospitals in the region able to provide life-critical surgeries such as kidney transplant.
The hospital’s capacity was significantly impacted by the devastating fire. 11 operating rooms were directly affected, as well as an endoscopy suite; experts estimate that the floors in some of the operating rooms may have reached 1000°C – the structural strength of unprotected steel begins to weaken at 550°C. To ensure the safety of all hospital users, extensive renovation of the theatre flooring was required, and services were suspended.
A catastrophic fire
Fire is a particularly devastating event for healthcare buildings. Hospitals are susceptible to wide-ranging smoke damage when a fire occurs due to the nature of their ventilation systems, which are often more extensive than in other commercial buildings; the smoke can access a much broader area through these systems. Once ventilation systems are compromised and shut down, air quality can no longer be maintained, and moulds, bacteria and viral spores can begin to develop in the air ducts. Ventilation systems must therefore be thoroughly cleaned before their use can safely resume, which is a lengthy process; all air systems must be revalidated prior to becoming active.
Equipment, particularly operating room furniture and digital equipment, can be expensive to replace and cannot always be sourced at short notice to provide immediate care in the aftermath of a fire. As an environment which provides care to patients whose immunity is compromised, whether long-term from illness or because they undergo surgery and are therefore more vulnerable to infection, all damaged areas must be cleaned, made sterile and validated through extensive testing before they can be reopened to surgical procedures. This process, particularly when multiple operating rooms are damaged, can be complex and time consuming.
Immediate interim solutions
In Guadeloupe, the CHU was the beneficiary of a great community effort; many other hospitals and clinics in the area opened their doors to patients from the CHU. But this additional burden on their resources was not sustainable in the longer term and it was not ideal for patients having to travel long distances for treatment. In the immediate aftermath of the fire, a field hospital comprised of military-style tents was also deployed to provide some interim care, but this was not a viable solution for the anticipated length of the renovation period.
However, the concerted local response allowed the CHU time to thoroughly assess the damage and the extent of the repairs needed to return the hospital to functionality. Renovations to the structural aspects and the ventilation ducts were deemed necessary to ensure a safe and compliant environment for both staff and patients, but this would take several months to complete, possibly as long as a year. In the interim, the French government called in a medical services specialist to provide a local answer to the sudden gap in patient care.
A collaborative, international effort
A joint solution was created that brought together technical advances from across Europe – mobile healthcare facilities from Q-bital Healthcare Solutions, architectural planning and enabling works from Dutch modular specialists Young Medical and medical gas installation and commissioning from Meditechnik, along with specialist ventilation systems from the Netherlands and medical devices from France.
Representatives from the companies were on-site at the hospital within days of the fire and consulted with experts from the hospital’s clinical team, the workers’ unions, and the island’s health ministry. Together, this multinational team designed a solution for a temporary surgical complex that would provide greater operational capability, rather than the field hospital deployed in the immediate aftermath of the fire.
The challenges ahead
There were many and diverse challenges to overcome to deliver this innovative solution. The first of these were environmental. Guadeloupe is an archipelago in the Caribbean, meaning that it is in a tropical climate area. Not only does it experience high humidity year-round, often at 90% or higher, but it is also subject to a lengthy rainy season and is at risk of hurricanes in late summer and early autumn.
In order to develop a temporary building complex robust enough to maintain service provision through these variable conditions, special air handling systems were installed to pre-cool the air before it enters the ventilation systems for the operating theatres. These systems chilled the air to approximately 14°C, which dehumidified it, before passing the air into the operating theatre facility. Once within the ventilation system in the theatre, the air was brought back up to 16°C and humidified to provide the optimum conditions for surgery. This two-stage system ensured that the theatres’ air handling systems were not overloaded and performed to the optimal standard, and that staff and patients experienced a comfortable, compliant environment throughout the complex.
Technical and clinical considerations
The project team also faced a number of technical challenges. The CHU is near the top of a hill, and the space chosen to hold the complex was not on level ground. This site provided the most immediate access to the necessary support services within the undamaged parts of the hospital, meaning that it was the best positioning to ensure patient safety and for easy workflows for staff. It was critical that the facility was as stable as a permanent building, so extensive preparation work was required to make the location suitable. The land was levelled off and hardstanding was laid, but the problem of weatherproofing remained.
To ensure that the complex was as safe and as robust as possible, the companies called in a local contractor with experience in healthcare construction. Together, they designed a concrete structure with elevated plinths, interconnected by concrete beams to create one cohesive foundation. The mobile units were lowered and then secured onto the concrete plinths, ensuring that the feet of the facility remained dry. This way the total weight of the complex was judged sufficient to protect it from being lifted by hurricane winds, and the entire complex would move as a whole in the event of earth tremors, reducing the risk of damage.
Other technical challenges arose from regulatory concerns. As the facility was going to provide emergency and trauma care, much of which includes orthopaedic cases, the operating rooms had to provide suitable clinical environments for this infection-sensitive surgery. For this reason, mobile operating theatres with laminar flow ventilation were shipped to the islands via freighter.
In addition, a post-operative recovery ward with HEPA air filtration was deployed, as well as an additional unit to provide staff with a changing area, a welfare zone and an administrative area. This last also served as the gateway to the new complex, ensuring that access could be suitably controlled by staff. Project management staff from the companies also liaised closely with the hospital’s own teams to ensure that local safety standards, such as fire safety, electrical safety and water testing, were met.
From a clinical perspective, one of the greatest challenges was in introducing medical gas into the theatre complex. Mobile facilities are usually served through integral medical gas banks from cylinders, but in this case the projected duration of the project and the logistics required made it more appropriate to pipe medical gases in from the hospital’s own supply. To this end, a specialist company was called in to develop a pipeline from the hospital into the operating theatres in the complex; modifications were made to the mobile facilities to ensure that the systems would be compatible, ensuring that the new temporary complex would meet the hospital’s needs.
A successful solution
The operating theatre complex was delivered successfully and remains in place today. Clinical staff from the hospital’s workforce adapted well to the new setting, providing a high-quality service that met the hospital’s rigorous standards. Many of them were pleased that this solution enabled them to return to their local place of work. Emergency surgical patients can now be treated more rapidly, as they no longer have to be transported to alternative sites further away, and patient access to surgical services is partially restored at the CHU.
Key to the success of this project was the international co-operation of all parties. Islands, like remote and rural areas, and towns with restricted access, are often serviced by one hospital; and if something happens to that hospital – such as a catastrophic fire – it can quickly turn into a much bigger healthcare challenge. A mobile or modular hospital can be deployed rapidly to ensure continuity of care in a facility that is built for the purpose and designed to last for many years, enabling a sustainable longer-term solution to be built. Such solutions can be set up even faster if already incorporated into disaster recovery plans in locations with spatial limitations.