15 minute read

Coping with Coronavirus in the Falklands

By Martyn Barlow, Estates and Engineering manager at the Falkland Islands Government’s King Edward Memorial VII Hospital (KEMH)

Martyn Barlow, Estates and Engineering manager at the Falkland Islands Government’s King Edward Memorial VII Hospital (KEMH), describes some of the particular challenges for he and his team with the outbreak of the COVID 19 epidemic –including maintaining a sufficient oxygen supply for wards, and general clinical use, protecting elderly and especially vulnerable patients, and reconfiguring or isolating ventilation supply and extract systems as a new ‘zoning’ system was implemented to keep those with COVID-19 away from other patients.

Located in the Islands’ capital Stanley, the King Edward Memorial VII Hospital is used to dealing with whatever comes through the door, and usually has the ability to evacuate the seriously ill or patients who need specialist care. This all changed when the COVID-19 epidemic started, as international borders closed, and flying to other countries became more difficult. The staff at the KEMH are bracing themselves to

A ‘Cold’ ambulance with drive-in swabbing space. receive patients exceeding 300% of what the hospital is designed for, with limited support.

There are 14 British Overseas Territories in various locations around the world, one of which is the Falkland Islands, located in the South Atlantic Ocean, and lying some 8,000 miles from the UK. The KEMH is a small 29-bedded hospital that serves a small civilian population of about 3,000 people, as well as a significant number of military UK Ministry of Defence (MOD) personnel who are based

A bottle filler at the hospital – one of the prime concerns of the Engineering team was the resilience of the medical oxygen system.

The rear of the King Edward Memorial VII Hospital in Stanley from the air.

35 miles from Stanley at RAF Mount Pleasant. Patients who require specialist care are generally flown to either Chile or the UK, and in the event of some acute cases, emergency evacuation or ‘Aeromed’ will mean that if a Civilian Air Ambulance is not available then the RAF will fly those patients to Uruguay. In such cases KEMH will provide clinical and engineering support to meet patient and equipment needs.

SAMPLES MUST BE FLOWN TO THE UK KEMH does not have the facility to carry out testing for COVID19 (although this is likely to change in the near future), so samples must be flown to the UK for analysis. With flight disruption, followed by transit time, and the time to process samples, this has at times meant a delay of up to 10 days in some cases. This means patients who present symptoms expected of the pandemic victims must be treated as confirmed coronavirus patients until proven otherwise.

As the engineering team started to look at the extra resource requirements needed to support COVID-19 patients, it became quickly evident that, due to the numbers of expected patients, we should expect to lose team members as they become incapacitated. The impact of such a scenario is potentially even more significant due to the small number of trained engineers at the hospital; key staff loss in such a small team could mean an inability to maintain life- supporting systems such as medical oxygen plant. To mitigate this risk, engineers with previous hospital engineering experience have been drafted in ready to replace critical team members on an emergency call-out basis. Other individuals with high levels of technical competence and engineering aptitude have joined the team and trained on various systems and procedures, the intention being that they will augment the main engineering team for the duration of the COVID19 threat, thus allowing any reduced engineering capacity due to sickness to be absorbed by these extra members of staff.

NEED FOR EXTRA MEDICAL EQUIPMENT The structure of the KEMH means that procurement of medical equipment is an engineering responsibility, alongside our remit for Capital Projects. However, all such projects remain suspended at the moment. It was clear early on that in order to meet the threat of COVID-19, the KEMH needed to secure extra medical equipment such as bottle regulators, Continuous Positive Airway Pressure (CPAP devices), ventilators, portable concentrators, and all their associated consumables to name a few. It was also anticipated that some of these items would either be difficult to source, or that there would be significant lead times due to demand. One of the issues for the Falklands is logistical supply given the vast distance from the UK, so things are usually transported by sea, but this is a 6-8 week process, and that is also dependant on the items being shipped being available right away. The MOD greatly assisted the Falklands Health Service, with a priority stores route established to allow us to fast-track critical items relative to COVID-19 straight to the islands. The UK Military need to maintain an operational capability wherever they are deployed, and this includes the Falkland Islands. If any of the tri-service personnel based in the local military base become ill, they could would require hospital support, and to that end, elements of the British Army 16th Medical Regiment were deployed to the Islands and stationed in the KEMH, augmenting the civilian staff; with them came extra medical equipment, increasing KEMH’s capability further. This opened up another potential logistical supply

route, and with access to previously unavailable military equipment, the British Army staff and their equipment would be used to treat any patients irrespective of whether they were civilians or members of the armed forces.

ZONING IN TO ‘HOT AND ‘COLD’ As contingency planning continued, it became evident that without the ability to confirm that patients were free from the virus, it grew increasingly unlikely that the critical Aeromed evacuation could be relied on. This opened up the possibility that the hospital would need to treat more seriously injured patients, as well as for caring for those showing signs of coronavirus. The hospital was immediately zoned into ‘Hot’ (C19 patients) and ‘Cold’ (non-C19) areas. The normally resident, elderly care patients were moved to another location, where they remain shielded, to protect them, and free up space within the KEMH. The area they had occupied now became the Cold Ward, while the existing area dedicated to secondary care became the Hot Ward. Further planning for escalation of the Hot Ward was also considered and put in place. Part of these plans required taking over a detached house normally used for sheltered housing and converting it to act as the Cold Ward, should the Cold Ward need to be moved.

SUPPLY AND EXTRACT SYSTEM ADJUSTMENTS As the hospital was zoned, the ventilation requirements were considered, and supply and extract systems reconfigured or isolated as required. A main consideration was reducing the potential for contamination, while another was to maintain air supply for the Hot Zone care workers, as there was a potential for staff wearing PPE to overheat. Most of the dedicated ventilation systems remained in the ‘Cold ‘areas of the hospital. However, the ‘general vent’ supplies both the Hot and Cold wards, as well as other areas, and so careful consideration was required.

One of the prime concerns of the Engineering team was the resilience of the medical oxygen system. Due to logistical challenges, the KEMH manufactures medical oxygen via two identical O2 concentrator plants. This is directly piped to the various areas that need it, which totals 39 points. The system is designed for one concentrator to run with the other in standby, with extra resilience afforded by two banks of three J-size bottles, which are independently switched. There remains an extensive supply of J-sized bottles held in reserve for the emergency bottle bank, and by chance an extra supply of medical oxygen bottles was already ordered when the pandemic started. The plant also has a small compressor, which can be used to charge medical O2bottles, but as a small such unit, charging one J-size bottle takes over two hours.

PHE PATIENT MODELLING When the KEMH received the Public Health England (PHE) COVID-19 patient modelling, it painted a very bleak picture of needing to cater for 300 per cent more patients than the hospital was designed to hold, with the Falkland Islands Chief Medical Officer confirming that the only patients being admitted would be those requiring oxygen. This created a huge problem, since as things stood, there was no way of delivering a sustained oxygen supply to that many patients, and it was not lost on the staff that

A ‘Hot’ ambulance with COVID assessment path and signs.

The air separation plant – cryogenic plant which will take liquid oxygen and fill gaseous medical oxygen into either J- or W-size bottles – had to be flown 8,000 miles to the King Edward Memorial VII Hospital in two specially laid-on aircraft.

they would probably know most, if not all, of the patients being admitted, which potentially included colleagues and family members. With no possibility of an Aeromed, and no chance of sending patients to another hospital, any breakdowns of critical systems would need to be repaired by the Engineering team, since site support from manufacturers was not possible.

With the PHE modelling in mind it was clear that the oxygen production on site was inadequate to support such numbers, even with a stockpile of prefilled bottles. With both concentrators running in parallel, if one plant became defective, the bottle charging capability would be lost, and the resulting loss in pressure would ultimately mean insufficient oxygen being delivered to patients. Technical support for the concentrator plant is usually provided by the manufacturer once a year; it undertakes planned preventative maintenance (PPM).

A LOGISTICAL CHALLENGE TO GET ENGINEERS ON SITE However, organising engineers to attend is a logistical challenge, and it can often take a number of weeks from the placing a first call to a manufacturer, to their staff arriving – even for emergencies. With the Falklands lagging behind the UK in terms of effects of COVID-19, there is an additional 14-day quarantine period in force for anyone coming off the South Atlantic Air Bridge (the UK MOD flight from the UK). Given that any technical support staff we do get are likely to be stuck on the Islands – increasing the likelihood of no on-site support, we soon realised that any engineering issues would need to be addressed by our ‘in- house’ team. If the oxygen manufacturing plant remained operational, there would only be a constant supply of oxygen for 54% of expected patients, even taking account the extra capacity provided by the newly supplied portable oxygen concentrators. The stockpiled J-sized bottles are expected to last 12 hours each, supplying 10 litres per minute, and with both plants running close to capacity the ability to re-charge medical oxygen bottles would be lost.

RISK OF CONTAMINATION There is a sizable cache of empty industrial oxygen bottles on the Islands waiting for return to the UK, but while it was confirmed that the KEMH does have the capacity to fill these bottles via its ‘bullnose’ connections, any contamination in the bottle cannot be verified. As medical oxygen is a pharmaceutical product, it is a drug administered by a doctor, and the risk of potential contamination was deemed unacceptable. BOC in the UK is, in fact, currently converting W-size bottles and supplying

Spare beds ready in the ITU.

the NHS to make up the shortfall of J-size bottles, but the turnaround for getting emptied bottles to the UK, filled, and returned to us in the Falklands would be too long. At the time of writing, the MOD has negotiated for a substantial number of converted W-size medical oxygen bottles for immediate issue, and is currently investigating flying the bottles to the South Atlantic. The UK MOD has secured an air separation unit (ASU) – a cryogenic plant which will take liquid oxygen (LOx) and fill gaseous medical oxygen into either J- or W-size bottles (or any other-sized bottles). This is a significant piece of machinery, and will require three civilian engineers to install and commission, and a further five military personnel to operate on a shift basis. The capability uplift the ASU represents is considerable, as it can fill eight bottles simultaneously (both pin- indexed and bullnose), it has enough LOx for 600 charges. The ASU itself will be installed at RAF Mount Pleasant, enabling the installation and operational crew to remain in quarantine on the base – eating, sleeping, and working separate from all other personnel, thus negating the need for the 14-day quarantine. The UK MOD, in conjunction with the Falkland Islands Government, will then look to ferry lorry loads of bottles to Stanley and the KEMH, where emergency bottle caches have been set up, as required.

LUCKY THUS FAR In reality the Falkland Islands have been lucky thus far, as the number of COVID-19 patients has been relatively light. This has allowed clinical and engineering staff to draft new procedures for this unprecedented situation, and to see if they work, thereafter altering them as required. The ‘Plan, Do, Check, Act’ approach has allowed us to review and improve systems we have put in place – a luxury many countries have simply not enjoyed. The Achilles heel for the KEMH will always be logistical supply; however, we have enjoyed strong support from the UK MOD in this area. The Engineering team has been forced to consider actions they would not have think about normally, raising issues in areas that were previously unknown, as well as successes in other areas. Our next focus will be to how to support the hospital if the current pandemic requires us to maintain this higher level of day-to-day activity for a sustained period. Our strategy here is to put arrangements in place so we can wind down to effectively carry on as normally as possible, and then simply revert to the higher operational tempo in short order.

ABOUT THE AUTHOR Martyn Barlow is the Estates and Engineering manager at the King Edward Memorial VII Hospital (KEMH) in Stanley on the Falkland Islands. He has been in post as the head of Hospital Engineering for 15 months, having, as he puts it, ‘been succession planned in’ from his previous role as deputy Engineering manager position. In addition to his engineering management role, he also runs all the Health Department Capital Projects.

Initially a Royal Navy weapons engineer – a role with a heavy electrical control engineering bias – he left the Senior Service after 17 years while serving in the Falkland Islands in 2007, working as an electrical technician in the private sector before being recruited to a facilities management role with the Falkland Islands Government (FIG) Civil Service.

While with the FIG, he worked in the tertiary education sector for three years, heading the Falkland Islands Apprenticeship Scheme. This role included promoting engineering careers to young Falkland Islanders, such as in hospital engineering, and guiding workplaces on how to balance vocational and academic requirements to meet the expectations of local industry.

He was invited to join the KEMH engineering team in 2018. Alongside his hospital engineering responsibilities, he continues to teach, and assesses for the local college. He is studying for a BSc (Hons) in Management of Healthcare Engineering, Technologies and Facilities at Eastwood Park, although this course is currently in stasis due to the pandemic.

This article first appeared in the June 2020 issue of Health Estate Journal (www.healthestatejournal. com), the monthly magazine of the UK’s Institute of Healthcare Engineering and Estate Management (www.iheem.org.uk).

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