Q&A: How to Build a Negative Pressure Wing in a Nursing Home—Fast!

It took Cedric Steiner, MBA, and his team about 14 days to build a negative pressure wing in a nursing home in Lancaster County, Pennsylvania. Steiner, a hospital administrator, recently sat down with Infection Control Today® to discuss how he pulled off that feat. “It was it was very quick how we turned it around, Steiner tells ICT^®. “And it needed to be.” As a result, though, his was the only long-term care facility that would accept patients with coronavirus disease 2019 (COVID-19) at that time. “Negative pressure space allowed us to treat people with COVID,” Steiner tells ICT®. “We were the only nursing home that would accept a resident with COVID at the time we put this in.”

Infection Control Today^®: Could you tell us a little bit about yourself and how you got involved in a project to build a negative pressure room in a nursing home?

Cedric Steiner, MBA: Sure. I was originally a teacher. I taught high school biology for about 18 years. Then I went on to do an MBA in health administration and partnered with a gentleman who was a longtime CEO in Texas, and he had gone on to do work internationally in infection control, nosocomial infection type stuff, and international hospitals. And we kind of came together as a partnership to work on international medical travel. And in the meantime, I also went on to nursing home administration. So, I found myself in a nursing home working on the practicum component of nursing home administrator’s license, right when COVID hit. In the meantime, I had this partnership with a hospitalist where we were working, looking internationally, and that’ll have to shut down, of course, because of COVID. That's a little bit of the background. I guess that’s probably good for a background. As far as where I’m at academically. It was actually really exciting. I actually enjoyed it. I mean, it was a great time to be there. People kept saying I hope this doesn’t turn you off to nursing home administration. But it allowed me to get right into it. And it was about two or three weeks when I was in and I was actually more concerned about the facility not being allowed to have me there because I was an intern. And we were really beginning to shut down. I mean, there were talks in Pennsylvania of not having students … and they did at one time. They took students out of hospitals, as I’m sure you’re aware of, but even the physical therapists and some of that other work, there was discussion of removing those individuals for a time. I was happy to be there because I didn’t want to get interrupted in the practicum.

ICT^®: Now we’re talking about a nursing home, right?

Steiner: That’s correct. A skilled nursing home. This nursing home that I was at in Lancaster County—and Lancaster County is said to be the Silicon Valley of nursing homes—we have some of the best nursing homes across the country. People come to Lancaster County. It’s Amish country. It’s pristine, and they like to retire here. Moderate temperatures and so forth. So, I was in a nursing home. It’s a CCRC [continuing care retirement community] for all intents and purposes. It had independent living, it had personal care and it had healthcare, which is skilled care, you know, rehabilitation type care. Anybody that gets out of a hospital with a knee replacement or something like that and can’t go home, you might end up in a skilled facility like ours.

ICT®: What gave you the idea, and what made you think you could pull it off?

Steiner: Well, I got I got to give a lot of credit to Shelly Miller. I did a little research, and Shelley Miller is a professor at the University of Colorado, Boulder. And I think she’s … as this interview goes out, she’s being featured on like PBS NewsHour and NPR and some other things. I think there’s a couple of them that are really top of the field in this area of buildings. And she had worked with Nick Clements in a conversion in Palo Alto, California, where they took a hospital and they did a net negative pressure ward on it. And I came across their research and I called her. She thought maybe it was a joke at first, but she…. Actually, I just got a text. She just sent me an email and said our paper was accepted for the submission. So, we’re good to go. We’ll have a paper out there.

ICT^®: That was at the American Journal of Infection Control?

Steiner: Yes, that’s correct. Just as we were talking, you know how that little flip the emails come across.

ICT^®: I’m a good luck charm then, right?

Steiner: [Laughs.] So, I reached out to her, and she got back to me. And I told her, “Hey, I want to do this. I want to do what you’re doing. I want to do it in nursing home.” I was definitely interested in publication. I was interested in writing and research. And her co-author had moved on to the Well Living Lab, which is part of Mayo Clinic. And those two, along with another gentleman at the University of Colorado, a mechanical engineer, computer sciences, we teamed up together with me on the ground, working with the administration, kind of knowing the nursing home, what goes on in a nursing home, and how things work on the ground. We were able to put together both the experiments. Nick would ship me the equipment and I had enough technical and computer expertise to get the data and collect it and set it up. We do things over zoom. We put that together. I gave her a lot of credit. She was willing to go for it. The administration at the nursing home was able and was willing to allow us to do it. We basically put in place the suggestions that Shelley had. I would kind of offer suggestions from a nursing homes perspective how they operate. But yeah, the building management people, the environmental control specialists who are in a hospital or in a nursing home, they did the actual mechanical work. They put in the motors and I took the data and made sure we were getting pressures we wanted in air exchanges we wanted.

ICT®: I’m trying to visualize it. You’re working in a nursing home. You’re a manager with a nursing home, right? You look around and you see a room that you might be able to use as a negative pressure room, right?

Steiner: We’re going to go bigger than that, because at the same time we were talking about up in New Jersey, I think they were putting that tennis court under all negative pressure, or they were at least making a facility inside. I wanted to do the whole wing and the way nursing homes have traditionally been designed is that they were designed after hospital models, so they have wings and corridors. A hospital and a skilled nursing home have a lot of the same features. We needed a lot of space. We wanted to put the whole wing under negative pressure. That was the goal. A whole section of the facility.

ICT®: Now, was your infections preventionist involved in what you were doing?

Steiner: Yes, correct. According to Pennsylvania, I think it’s chapter 28 of the PA code, you’re required to have an infection prevention nurse. And that nurse is responsible for recording infection control methods. I think it was originally to address TB, and some of those type things. But more recently, it has to do a lot with influenza. So yes, we have that in Pennsylvania. Everybody is required. So yes, we had an infection control nurse who was on board with this as well.

ICT®: Did you have to relocate the residents?

Steiner: We just moved them around the facility. And at the time hospitals stopped sending residents to us. Remember, they shut down there. A lot of their surgeries. We were using a what was a rehab wing, where people with knee replacements, hip fractures, things like that would have come in. We were starting to get fewer and fewer admissions. We were able to find the space and move people out. So that essentially, we had 13-room wing that was open to new admissions.

ICT®: How long did it take?

Steiner: It went really quick. I think from the day I first talked with Shelly to the day we took our admission, I think it was is about 10 days. It might have been 14, but it was it was very quick how we turned it around. And it needed to be at that time, because in Pennsylvania, we were hearing we were going to get admissions from hospitals, and we were going to need to take COVID residents. So, we knew we’d have to put these people somewhere. And there was another concern. We didn’t know who would come into the facility with COVID. And so, we had to do an isolation and we didn’t have the testing that early on. You had to isolate. The best thing we could do is bring somebody in and isolate them in this ward. And since it was under negative pressure, we weren’t putting a resident with another resident. Traditionally, in nursing homes, it’s not independent rooms. Residents share rooms, and then they shared skilled nursing staff. CNAs will share. And that just that just spread it all over the place, once you had that kind of thing. We really were able to isolate it not only a negative pressure…. And we were being required by the Department of Health to come up with an isolation space. We just made it all that much better by putting it under negative pressure.

ICT®: With a project like this, how do you measure success? First of all, you get it done, you get the negative pressure wing functional. That’s success. But then after that how do you measure success?

Steiner: Negative pressure space allowed us to treat people with COVID. We were the only nursing home that would accept a resident with COVID at the time we put this in. That was a huge success right there. Now, some people thought that was irresponsible by the administration to bring in somebody to treat them. But we were able to bring in people, we could treat them in that COVID unit and we could then discharge them. And we did that all without using it as a separate facility. That was a huge success in itself, being able to treat people. And the other success was our own staff. And for me, kind of my area in health administration is really about staffing and protecting staff. This made an environment where staff felt more comfortable. And I don’t know if anybody else has told you this along the way, but some of the nursing staff felt better being in infection control units than outside. Where things were kind of a toss-up on the outside, when you went into an AIIR [airborne infection isolation] room, you had all the proper PPE. You felt like the precautions were there. And you felt comfortable. Time and time again, I would hear from staff that they felt more comfortable in that isolation space than they did maybe in other parts of the nursing home where there was more exchange and more unknowns.

ICT®: Has anybody reached out to you from other healthcare institutions? I’m talking about long-term care facilities. Has word gotten out and do they want to do the same thing?

Steiner: Immediately other facilities began doing their own type experiments with this. I don’t know if anybody doing is quite what we did. We were using engineers. And we were doing it very academically on experimental basis. I think they were calling in HVAC [heating, ventilation and airconditioning] specialists. I would caution anybody watching this, we had an HVAC specialist come in and I will tell you, I was concerned with their plan. They have an idea of what’s going on. But as far as infection control, your HVAC people, they’re not infection control people. They can do things, but I would really caution you against…. You should seek professional engineering advice on these. Just don’t bring in an HVAC guy and ask him to go negative pressure or do something because they’ll, in my experience, they actually confuse positive pressure with negative pressure. I have heard of different things like that. And I’ve even heard of other solutions. In Pennsylvania, the major solution seems to be we’re going to test residents and staff. I mean on a weekly basis and so forth until we can find where we’re at.

ICT®: What sort of data were you collecting?

Steiner: Specifically, the data that we were collecting out of the rooms where were actual pressures. We wanted to see the pressure. It’s really called a cascading pressure zone. It’s the way in which it would work. That’s how you should think about it. The rooms need to be negative to the hallway. The hallway negative to an anteroom and the anteroom negative to the outside air. So essentially, air that is coming into this facility is always moving away from the patient and out of the facility. There were a lot of vents in the room. Air was coming down the hallway out the patient’s room in such a way that hopefully our healthcare providers in the hallways, and in the in the anteroom, the air was always coming in from…. In our case, it had to come in from somewhere. It was coming in from the facility to be supplied. So I knew those pressures. I had a computer and a monitor setup in the back. I had equipment from the Well Living Lab, and I would be reading those pressures and emailing them out to the to the engineers on a daily basis.

ICT®: Any final thoughts?

Steiner: You can only work as a nurse with tools, right? And I guess we’ve never really considered the building a tool, right? I mean, do you consider the actual air, the air-handling facility a tool? And that’s really where we’re going. And in nursing home codes…. They have in the code, Chapter 28, I believe, again, in Pennsylvania, says the pressure differences from different facilities. So, for example, like a laundry chute needs to be negative to the hallway. It’s usually around smell or something like that. When we talk about infection control, and not just one room, but pieces of the facility, we’re definitely on the right track. And I think we need to start thinking about the building as like a living, breathing kind of thing. And getting your air and how you’re going to move that air and how many exchanges you have. I think currently, it’s like two to six exchanges. And Shelly’s talking about 12 exchanges. We I think they’re on the right track. I think that we ought to think about buildings a little differently. And I think that as far as an infection control nurse, that that can be something that they need to put on their radar. They can do these mechanisms. They can keep track of hot zones and all of those kind of things. But, you know, maybe they need to be advocates for healthy living spaces or healthy buildings and breathing buildings.

This interview has been edited for length and clarity.