COVID-19 is proving the wisdom of healthcare design – what more can we learn?
By Chris McQuillan, B.Arch., FRAIC, OAA, LEED AP
We live in an amazing time. Deaths from conflict (of all kinds) are at historic lows and we have triumphed over diseases like Small Pox, Measles, and Polio among many others. As a society our focus on disease tends to be limited to mitigating lifestyle ailments or weathering the annual flu. Up until a few months ago the greatest risk we face – infectious disease – had slipped from our consciousness. A quick study of historic data shows that over the last 500 years, epidemics account for a death rate three to seven times that of conflict . With the advent of modern medicine our solution to these risks took the physical form of the healthcare system. Since the mid 20th century our facilities have grown in complexity and resources to respond to every health challenge conceivable.
In recent times, several diseases – chiefly SARS, MERS and H1N1, have attained widespread notoriety and challenged the best healthcare and medicine we can create. Hospital design has evolved in response and the lessons learned during these epidemics, particularly evident in those locales that were hardest hit by recent challenges, are proving important in helping our healthcare systems respond to COVID-19. We have cause to celebrate some of the essential innovations keeping us safer today:
Clean hands – infection studies have long shown that person-to person contact and physical contact with surfaces or through droplet spread, are common ways that microbes and viruses spread. Prior to the SARS pandemic, standards for hand-hygiene stations in hospital were inconsistent and often not applied. A key innovation was to codify a standard wherein every environment that involves patient-caregiver contact is equipped with a conveniently placed dedicated hand hygiene station (ideally a dedicated hand-washng sink, if not feasible an alcohol-based hand rub – AHRB). Can anyone remember what hospital entrances looked like without the ‘Purell stand’?
A clean environment – Experience with highly contagious diseases placed new emphasis on the ability to decontaminate many, if not all, areas of the hospital. Science studied the effects of using various building materials and how these materials inter-react with contagion and cleaning. Findings from this examination have led to a significant change in all materials used in the interior finishing and furnishing of healthcare facilities. We now solely use non-porous materials with minimized/shallow joints and avoid shelves and recesses that are difficult to clean. We use technologies such as copper/ silver ion coatings and UV light sources to actively decolonize surfaces and entire rooms.
Isolation – Prior to SARS, hospitals had little physical infrastructure to isolate patients suffering from respiratory ailments. During that crisis, many facilities constructed ad-hoc air handling systems or worked to re-balance building infrastructure to provide local or zoned isolation so that contaminated areas or individuals could be separated from uncontaminated areas. In subsequent years, and in all new hospitals, every department is equipped with isolation rooms (usually 5-10% of the spaces) and has the ability to separate zones of whole departments from the balance of the facility to give caregivers a variety of options to contain infection.
Single bedrooms/ treatment bays – For anyone entering a hospital and wondering if it were designed before or after SARS, the clearest evidence is that the latter contains a far greater number of single and hard-wall enclosed treatment spaces and bedrooms. Before SARS, it was quite normal in emergency departments to separate most treatment bays with curtains. Similarly, inpatient units were often designed with a majority of semi-private rooms and even some wards (4-beds). Single bed rooms were few and reserved for those who could pay. It quickly became apparent that patient bedrooms and treatment areas needed to be designed and built to allow isolation. The rooms can be negatively pressurized relative to the corridors. Thresholds provide ideal areas for PPE protocols, decentralized nursing stations are located to support local access to patient data and to maintain clear view corridors to patients without needing to enter the room. With such a large number of curtained cubicles and shared inpatient beds in older hospitals the ‘functional isolation’ capacity was, in fact, much lower than the bedcount. Today, virtually every bedroom, exam room and treatment area can be adapted for patient isolation.
Separation of flows – SARS and MERS presented unique challenges in managing the flows of patients and caregivers within the facility. Due to a heightened awareness of contaminated people and wastes, routes for patients and materials (particularly those associated with the treatment areas) were kept separate from other people and materials in the building. In many facilities, particularly older buildings, department floor areas often had a single point of access. Flow separation (patients from supplies from public) was typically not maintained as a matter of priority or it was postponed until after business hours. In a pandemic scenario, these options are not available. More recent planning aims to maintain separate clean and soiled areas, to minimize the depth of ingress of dirty flows into departments, to place isolation spaces at departmental perimeters, to separate access for staff and materials from patients and families, and to provide diversity of access so that portions of some departments can be independently accessed to treat different patient populations.
Access & Screening – Access points to healthcare facilities changed as we considered how to screen all people entering the buildings. In addition to heightened security, the number of access points has been reduced and separation of the different flows (patients, staff, wastes, supplies) has been enhanced. Overall planning has responded with a clearer definition of a contiguous front-of-house ‘public zone’ whereas historically the boundary between public and functional areas and access points was much less sharply defined. In addition, the footprint of access points needed to grow to accommodate screening stations and space to don and doff PPE. Examination of a spectrum of presentation risks determined the provision of additional outdoor space to allow the construction of temporary structures and services for such purposes as physical decontamination. All of these interventions allow our healthcare facilities far greater control over the status of people and materials entering and exiting.
The collective impact of these advances has readied us to handle far greater numbers of acute COVID-19 cases within our hospitals. We can safely separate staff and patients from each other and facilitate the turnover of spaces for successive waves of patients. While there are many other limiting factors relating to the sustainable level of pandemic care (including staff and supplies) our physical infrastructure is as ready as it has ever been.
In the midst of this pandemic, we’ve all raised questions about how our healthcare facilities will need to change, both to rise to this challenge and to prepare us for a similar outbreak in the future. A likely truth is that hospitals are very close to what they need to be to respond – we are close to the point of diminishing returns when we look at the buildings we traditionally consider as the places of care delivery.
The next frontier has been highlighted by our dependency on the ready availability of consumable supplies and key equipment (notably ventilators) to act as the first line of defence between caregivers and their patients. This is not a physical challenge but rather a logistical one. Healthcare already represents a high percentage of GDP in many advanced nations. Substantially investing in more healthcare infrastructure is likely to be unsustainable.
Our greatest opportunity to improve our response lies in harnessing other assets in our built environment. The lessons learned in effective hospital design can be applied to other buildings in our urban fabric, at various scales, to create a sustainable rapid response model at a local scale.
Our greatest opportunity to improve our response lies in harnessing other assets in our built environment. The lessons learned in effective hospital design can be applied to other buildings in our urban fabric, at various scales, to create a sustainable rapid response model at a local scale.