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Keep the emergency department (ED) operating by building the replacement capacity, routes and utilities first; then isolate and renovate one zone at a time. Before every move, the hospital’s multidisciplinary team completes an infection-control risk assessment (ICRA) and broader pre-construction risk assessment, confirms temporary clinical capacity, verifies life-safety systems and briefs staff. During construction, it monitors barriers, pressure, airflow, dust, moisture, noise, vibration, traffic and available beds. A zone returns to service only after cleaning, testing, commissioning and documented clinical acceptance.
What a safe phasing strategy must achieve
Phasing is an operational design problem, not merely a construction schedule. The sequence must preserve timely assessment, resuscitation, imaging, medication access, staff support, ambulance movement and fire egress while work occurs beside occupied clinical space. A phase is acceptable only when the hospital can demonstrate that patients still have a safe route and a clinically usable destination if the construction area is unavailable.
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Use an enabling-works-first, zone-by-zone sequence. Enabling works create temporary treatment and support areas, protected circulation, replacement utilities and communications before the existing area is shut down. Each subsequent zone then has a defined decant location, a controlled construction boundary and objective turnover gates. If a surge, utility failure or infection-control event occurs, the plan should permit a pause or reversal rather than forcing the ED to operate in an unsafe configuration.
Hospital codes, fire and life-safety rules, accreditation requirements, ambulance-diversion rules and adopted code editions vary by jurisdiction. The project’s infection-prevention team, authority having jurisdiction and clinical leadership must approve the local requirements before work starts.
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1. Establish governance and map the existing operation
Create one decision-making team
Give the phasing plan a named owner and a multidisciplinary team with authority to stop work. Include ED clinical leadership, infection prevention, facilities and engineering, construction management, safety, security, environmental services, emergency management, communications and infection-control staff. Include imaging, pharmacy, laboratory, nursing, respiratory therapy and medical-gas specialists when their services or routes are affected.
CDC construction guidance recommends a multidisciplinary construction team and summary statements of its activities. Put infection-control obligations, reporting duties, correction time frames and stop-work provisions in the construction contract. Workers and affected clinical staff need orientation before entering a new phase, not after a problem occurs.
Map every movement and dependency
Draw the current and proposed paths at operational scale. Map:
- Ambulance approach, unloading, handover and departure.
- Walk-in entry, registration, triage, waiting and accessible routes.
- Patient movement to resuscitation, treatment, observation, imaging, operating rooms and inpatient units.
- Staff entry, break areas, changing rooms and emergency exits.
- Clean supplies, medications, specimens, waste, linen, food and construction deliveries.
- Fire-department access, fire compartments, smoke doors, stairs and protected egress.
- Medical gases, domestic and process water, drainage, power, emergency power, data, nurse call, security and public-address systems.
Record widths, door clearances, turning radii, elevator limits, infection-control boundaries and times when routes are busiest. A route that works on a plan may fail when a stretcher, portable imaging unit and waste cart meet in the same corridor.
Set communication and escalation rules
Assign a communication authority for each shift. Maintain a daily issue log covering barrier condition, pressure readings, utility status, incidents, near misses, noise or vibration complaints, route changes and available clinical capacity. Define who can halt demolition, who can authorize a route change, how the ED is notified, and how an ambulance service is informed if access or arrival capacity changes.
2. Build the clinical continuity and decant plan
For every phase, list exactly what is unavailable and where that function moves. Do not describe a space only as “closed”; identify its clinical consequences.
Define the phase inventory
At minimum, identify the beds, triage positions, resuscitation bays, treatment rooms, imaging links, medication rooms, clean and dirty utilities, staff work areas, toilets and storage that will be lost. Note whether the loss is continuous, intermittent or limited to particular shifts. Match each loss to a pre-approved temporary location, staffing model, equipment set and route.
Pre-approve surge and diversion actions
Write trigger-based actions for a sudden increase in arrivals, a major incident, an infectious-disease concern or a construction incident. Options may include opening overflow treatment, moving triage, using an alternate imaging path, restricting nonurgent activity, calling additional staff or coordinating ambulance communication. The plan should state who makes each decision and how quickly the change can be implemented.
Do not assume that a temporary room is clinically equivalent to the room it replaces. Confirm oxygen and suction capacity, electrical outlets, emergency power, monitoring, privacy, hand hygiene, medication security, staff visibility, patient observation and accessible egress. Obtain clinical sign-off before the area is counted as capacity.
Design for future change
NHS England’s HBN 15-01, published in 2013 and updated on its page in 2024, describes a method for designing or redesigning an accident-and-emergency department that can change and expand for future demands. Apply that principle to temporary as well as permanent work: place services so later phases can proceed without repeatedly crossing occupied treatment areas, and preserve spare routes and connection points where feasible.
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3. Complete the ICRA and broader pre-construction risk assessment
Complete the ICRA before demolition, drilling, ceiling access or utility interruption. Refresh it whenever the scope, patient population, adjacency, construction method, work hours or temporary route changes. Pair it with a broader pre-construction risk assessment covering operational and life-safety hazards.
Assess the environment and the work
Evaluate:
- The design and function of the new or altered area.
- Patients at increased risk from airborne infection, dust, noise, vibration or loss of pressure control.
- Dust and moisture generation, including demolition, coring, roofing, plumbing and fire-suppression work.
- Airborne-disease prevention opportunities and surveillance requirements.
- Noise and vibration effects on sleep, monitoring, imaging, communication and sensitive equipment.
- Water intrusion, leaks, mold potential and wet materials.
- Hazardous materials, sharps, chemicals and contaminated building components.
- Utility shutdowns, temporary feeds, emergency power, medical gases, fire alarm, sprinklers, smoke control and communications.
- Fire protection, compartmentation, emergency exits and the ability to evacuate patients who cannot walk.
- Construction traffic, deliveries, debris removal, security and public access.
Public Health Ontario organizes construction, renovation, maintenance and demolition controls through planning, work and commissioning. Use that same lifecycle: controls are selected before work, verified while work is under way and tested before the space is occupied.
Classify controls and acceptance criteria
The ICRA should state the required barrier type, work-zone pressure relationship, air-handling arrangement, filtration, cleaning frequency, worker protective measures, patient relocation requirements and inspection schedule. It should also name the person who verifies each control and the condition that triggers a stop. “Keep dust out” is not an acceptance criterion; a sealed barrier, negative-pressure target, inspection record and corrective action are.
4. Complete enabling works before isolating the ED
Enabling works are the practical difference between a controlled phase and an emergency improvisation. Build and test temporary walls, protected routes, treatment spaces, utilities, communications and storage before closing the permanent area.
Provide temporary clinical infrastructure
Equip the decant area for its approved function. Verify medical gases, emergency power, normal power, lighting, data, nurse call, monitoring, hand-washing, medication storage, waste handling, fire alarm coverage, sprinkler protection, privacy and accessibility. Label temporary rooms and routes clearly so staff, patients and emergency responders do not rely on memory.
Protect ventilation and pressurization
Preserve required pressure differentials, air changes and filtration for occupied clinical spaces. Coordinate every shutdown with infection prevention and facilities engineering. CDC guidance says patient-care HVAC should not be shut down except for maintenance, repair, emergency-backup testing or new construction, and calls for backup air-handling and pressurization systems. If a temporary system is used, test it under the expected door-opening and occupancy conditions before patients move in.
Test before the move
Run a formal readiness walk-through with clinical, engineering, infection-prevention, security and environmental-services representatives. Verify routes with an actual stretcher and equipment; test emergency power transfer, alarms, medical gases, communications and door operation; confirm signage and accessible egress; and record deficiencies with owners and deadlines. Clinical leadership should accept the temporary area in writing.
5. Isolate and construct one zone
Once the replacement capacity and routes are ready, isolate one construction zone. Keep the zone as small as practical while preserving a coherent work package; repeatedly reopening a boundary creates more risk than completing a properly planned area.
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Use sealed rigid barriers where the ICRA requires them. Seal joints, penetrations, ceilings, floors and service openings. Provide a controlled worker entrance, a material route and a debris-removal method that does not cross patient circulation. Post hazard notices and signed detours at every decision point, not only at the work-zone door.
Maintain negative pressure and inspect it
Maintain negative pressure in work zones adjacent to patient care when specified by the ICRA. Use an engineered exhaust or air-scrubbing arrangement that discharges safely and does not pull contaminated air into occupied areas. Monitor pressure or airflow continuously where feasible, inspect barriers at the start of each shift and after deliveries, and repair gaps immediately. A pressure alarm without a response procedure is not a control.
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Separate people, materials and waste
Schedule deliveries and noisy work away from peak arrival periods when possible. Keep construction workers, patients, clean supplies, waste and debris on separate routes. Use covered carts, clean wheels before leaving the work area and prevent staging in egress corridors. Security should control access and know the location of temporary treatment areas and alternate exits.
Relocate high-risk patients when required
Use the ICRA to identify patients who are especially vulnerable to airborne contaminants or disruption. Relocate them before work begins when the risk assessment indicates that barriers, pressure or distance cannot provide adequate protection. Document the decision and reassess it if the work method changes.
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Use layered dust controls
Containment, negative pressure, source control, wet methods where appropriate, sealed waste removal and frequent cleaning work together. Portable filtration is an adjunct, not a substitute for a sealed barrier, correct pressure relationship, HVAC design or the ICRA.
CDC environmental-infection-control guidance specifies portable, industrial-grade HEPA units with filtration rates in the range of 300–800 ft3/min. It says suitable units can provide the equivalent of at least 12 air changes per hour, depending on room volume and operating conditions. Facility engineers should select placement, confirm electrical capacity and verify performance before the room is returned to service. Procurement should also verify certification, noise, heat output, alarms, maintenance and availability for the project’s jurisdiction.
Prevent moisture events
Protect occupied areas from leaks, condensation and wet materials. Isolate plumbing work, monitor ceilings and adjacent rooms, keep absorbent materials out of patient areas and establish an immediate response for a leak. A wet barrier or ceiling cavity can spread contamination beyond the visible work zone; stop work, isolate the affected area and involve infection prevention and facilities engineering when moisture control fails.
Manage noise and vibration as clinical hazards
Identify procedures, patients and equipment affected by noise or vibration. Schedule high-impact work during approved windows, notify clinical leaders, protect sensitive equipment and provide a stop trigger for deterioration in patient care, communication or monitoring. Record complaints and near misses in the daily issue log rather than treating them as informal feedback.
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Utility work is often the point at which a seemingly isolated renovation affects the whole ED. Trace each service to its source and destination, identify single points of failure and install temporary or redundant feeds before disconnecting the existing system.
Use a written shutdown procedure
For every interruption, document the affected rooms, start and end time, clinical owner, engineering lead, backup system, verification test, notification list and restoration criteria. Coordinate power, water, medical gases, HVAC, fire alarm, sprinklers, data, nurse call and security separately; one “utilities off” notice is not enough.
Protect life safety continuously
Keep required fire compartments, smoke doors, alarms, sprinklers and emergency exits operational. If a temporary impairment is unavoidable, obtain the required approvals, provide compensatory measures and communicate the impairment to staff and responders. Walk the evacuation route with the types of patients the ED actually treats, including stretcher and wheelchair users.
Keep ambulances moving
Maintain a physically clear, signed ambulance approach and handover path. If a route, canopy, bay or radio channel changes, agree the trigger and message for ambulance services before the phase begins. A temporary route should be tested at the largest vehicle and stretcher combination expected, in daylight and under the site’s restricted-visibility conditions where relevant.
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8. Commission and turn over each completed zone
Commissioning is a distinct phase, not a cleaning task at the end of construction. Keep the zone out of clinical use until the required tests and approvals are complete.
Use a documented turnover checklist
- Remove tools, debris, temporary materials and unapproved furnishings.
- Complete construction cleaning and terminal cleaning using the hospital’s approved procedures.
- Verify pressure relationships, airflow, air-handling operation, filtration and any temporary exhaust or HEPA equipment.
- Test normal and emergency power, lighting, medical gases, water, drainage, data, nurse call, security, fire alarm, sprinklers and smoke-control functions relevant to the zone.
- Confirm doors, hardware, accessible routes, fire compartments, signage and emergency egress.
- Check finishes, seals, penetrations and moisture condition; document any outstanding defect and its interim control.
- Run a clinical simulation with the equipment, staff and patient routes that will be used in service.
- Brief staff on the new layout, isolation points, emergency procedures, cleaning requirements and escalation contacts.
- Obtain written infection-prevention, engineering, safety and clinical acceptance.
FGI phasing provisions call for clean-to-dirty airflow, emergency procedures, interruption criteria, written notification and communication authority, with renovation areas isolated from occupied areas based on the ICRA. Keep test results, cleaning records, staff attendance, approvals and as-built route drawings in the project record.
9. Close one phase before starting the next
Hold a phase-closeout meeting while the experience is fresh. Review incidents, near misses, barrier failures, pressure excursions, utility interruptions, patient-flow delays, complaints, cleaning findings and any unplanned capacity loss. Update the ICRA, risk register, route drawings, contact list and decant assumptions before releasing the next zone.
Use a formal acceptance gate: the next phase cannot start if required temporary capacity is unavailable, a life-safety system is impaired without approved controls, pressure or barriers cannot be maintained, a route is inaccessible, or clinical leadership has not accepted the operating arrangement. This rule turns lessons into a safer sequence instead of repeating the same exposure.
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There is no universally best sequence. Compare each option against the same operational criteria and record the trade-offs with the people who will run the ED.
| Decision axis | Questions to answer | What a stronger option demonstrates |
|---|---|---|
| Clinical capacity | How many beds, treatment functions and support rooms are unavailable in each phase? | Capacity remains clinically usable, with surge and high-risk-patient actions pre-approved. |
| Ambulance and patient routes | How much longer are routes, and do they remain accessible for stretchers and emergency vehicles? | Separate, signed routes are tested in real operating conditions. |
| Utility interruptions | How many interruptions occur, how long do they last and what backup is verified? | Shutdowns are minimized, scheduled and supported by tested temporary systems. |
| Infection-control risk | How complex are barriers, pressure control, dust removal and moisture protection? | The ICRA controls are practical to inspect and maintain every shift. |
| Temporary-space and equipment cost | What decant rooms, filtration, power, security and staffing are required? | Cost is evaluated alongside clinical reliability, not as a standalone lowest bid. |
| Schedule certainty | Does the sequence depend on uncertain shutdowns, approvals or hidden conditions? | Enabling works and commissioning gates expose uncertainty early. |
| Reversibility | Can the hospital pause or restore capacity during a surge or incident? | The plan has a defined rollback route and does not consume every usable clinical space. |
Common failure modes and the corrective response
A barrier is intact visually but pressure is wrong
Stop affected work, protect patients and verify exhaust, door operation, penetrations and monitoring equipment. Repair and retest before resuming. Do not compensate for a failed barrier by simply placing a portable filter in an occupied corridor.
A temporary room exists but cannot support the intended care
Remove it from counted capacity, identify the missing oxygen, power, monitoring, staffing or egress capability, and correct the deficiency before decanting patients. Clinical acceptance must follow testing, not precede it.
A utility shutdown lasts beyond its approved window
Activate the written escalation path, notify the clinical and emergency-management leads, use the verified backup or rollback arrangement and reassess ambulance and patient-flow actions. Record the event and change the next phase plan.
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Construction traffic conflicts with patient movement
Stop the conflicting delivery or movement, restore the protected route, revise delivery times or access control and brief the affected teams. Repeated conflicts indicate that the route design, not individual behavior, needs correction.
Moisture or dust escapes the zone
Isolate the affected area, protect or relocate patients as directed by infection prevention, clean and assess adjacent spaces, correct the source and document clearance criteria. Do not reopen based solely on a visual inspection.
What to keep in the permanent project record
- Approved phasing drawings, route maps and decant schedules.
- Current ICRAs, pre-construction risk assessments and revision history.
- Barrier, pressure, airflow, temperature, moisture and cleaning logs as applicable.
- Utility shutdown permits, backup-system tests and restoration records.
- Fire and life-safety impairment notices, compensatory measures and approvals.
- Training and briefing attendance, daily issue logs, incidents and near misses.
- Commissioning results, terminal-cleaning records, defect lists and clinical acceptance forms.
- Updated as-built information showing isolation points, temporary routes and emergency contacts.
These records let the hospital demonstrate that each phase was controlled and give the next team reliable information instead of assumptions.
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