Seeking to gain a deeper understanding of what has been happening in the industry throughout the COVID-19 pandemic, FCA conducted a series of interviews to gain first-hand knowledge of the key design issues clients have been dealing with.
Healthcare facilities have been largely unprepared for the COVID-19 pandemic and have faced enormous challenges over the past two years as a result. Hospitals and healthcare systems alike are taking an in-depth look at the changes that can be made from an operational and design perspective to better prepare for the common diseases of the future.
FCA conducted a series of interviews over a five-month period with 15 key stakeholders from six healthcare organizations in the Northeast, both urban and suburban, to understand the key takeaways and the overall impact of COVID-19 on the industry. A list of standardized questions about patient care delivery, general interaction, staff fatigue, medical equipment, and indoor air quality was used in virtual interviews with senior officials, physicians, nurses, facility teams, and support services staff.
Here are some of the main findings.
patient care delivery. Looking at the delivery of patient care, the survey focused on three primary areas: patient treatment, use of spaces, and cleaning protocols.
We identified a set of key patient care-related outcomes that include minimization of patient interaction, lack of equity between facilities, altered standards of care delivery, patient perception, and increased use of temporary surge units.
Several sites reported that they reduced staff and patient interactions during steep increases. Although this is not surprising, it is interesting to note the way in which the facilities have uniquely dealt with these challenges, particularly in terms of patient care. In existing medical/surgical bed units, a number of temporary waiting rooms have been constructed and wall sleeves installed between the corridors and patient rooms to allow control of equipment from the corridors.
Most of the people interviewed also indicated that they used temporary increment units. Space types varied from reassigned perioperative recovery areas to modified behavioral units, ORs, and other medical/surgical units. Medical gases and temporary exhaust ventilation have been added to support patient care in these temporary treatment spaces.
general interaction. Participants in the facility team relayed how their creativity and resources helped solve problems during the height of the first wave and how this experience would influence the design and planning of future projects. Solutions ranged from screening at entry points to ways to improve airflow to intensive care rooms.
At the start of the pandemic, screening everyone entering facilities was critical, and with limited knowledge of COVID-19, the quickest and simplest diagnostic procedure was fever monitoring. Technology was used to record the temperature and quickly identify any potential infections. The facilities quickly installed the necessary power and data at entrances to implement remote thermal scanning and temperature guns, which continue to be used in hospital settings and have also been deployed across outpatient settings.
Staff stress. Healthcare workers continue to be affected by COVID-19, as they face staffing issues, not just from within the hospital system, but on a global scale. Before the pandemic, the health care industry as a whole was facing a staff shortage of nurses and doctors according to the American Nursing Association and the American Hospital Association. Staff fatigue, anxiety, mental health, and loss of respect and trust from the general public are cited as reasons why people leave the healthcare workforce.
Participants also indicated that employees were concerned about keeping their families safe at home. Inpatient units usually do not have designated areas for staff to put on and take off PPE clothing. Rooms are designated for this purpose; However, staff still did not feel comfortable going home in the clothes that were inside the hospital. Many were changing their cars or garages to keep their homes and families safe from infection. This was especially true during the pandemic’s first year, but as more was known about the disease and more vaccines became available, concern about it decreased.
Medical Equipment. The ventilators were stockpiled in case of another boom, while Bi-pap and CPAP were actively used to keep people off ventilators. This type of equipment presents constant challenges for employees as cleaning and storage operations must be constantly rethought.
Hospitals have been innovative in the use of spaces not designed for critical care patients, such as waiting areas and meeting rooms. They had to quickly change standards of care delivery, based on available resources (location, staff, equipment) on a daily basis. The high patient acuity required direct monitoring and the staff found communication difficult due to the unit’s current internal architecture which was not designed for critically ill patients.
The growing presence of technology across many facilities has helped solve some of the communication and visualization challenges. Medical teams created available resources and used baby monitors to monitor patients while meeting the needs of other patients. Today, baby monitors are being replaced by cameras specifically designed for healthcare environments.
Allocation of units in COVID-19 units has been the biggest change hospitals have faced. Engineers, contractors, architects and facilities teams worked together to devise ways to modernize patient rooms. The converted units underwent changes in doors, electrical requirements, and increased air exchange. Changes to solid doors were a safety issue for staff and patients, as being able to see the room from the corridor was critical with this highly contagious disease. In a typical medical/surgical unit, graphs are made in a central location, but with ICU patients, direct monitoring is needed, and staff find themselves sitting in corridors with computers. Power and data have been added at locations outside of the rooms so that this neighborhood can be maintained.
Air quality indoors. Interviewees mentioned that at first it was thought that indoor air in patient rooms would require not only outdoor air but also HEPA filtration systems. Many have mentioned that curtain wall systems have been retrofitted with HEPA filtration systems. After learning more about how the virus spreads, these rooms were changed to full exhaust with additional air exchange in the patients’ rooms.
Survey respondents stated that most of the filtration systems had to be modernized and were not able to handle the amount of air exchanges required as well as the increase in direct exhaust. Most hospital buildings are designed without operable windows, so providing fresh air has proven to be a challenge to accommodate the ventilation and direct exhaust required. New projects being planned are considering operable windows and include higher air levels
5 future audit design strategies
The pandemic has changed both health care delivery and how facilities are designed. As more project teams look for design elements to demonstrate future boom and pandemic spaces, here are some considerations:
- Planning major health events for residents. As hospitals continue to address the sudden surge in COVID-19 patients and make evolving knowledge about the pandemic and its variables, they are gaining an understanding of what it takes to accommodate large population health events. This will not go away and new major health events will occur for the population. It is necessary to consider architectural solutions such as the queuing sequence to enter the larger lobby that allows for safe temperature scanning and facility entry.
Separating the staff entry sequence is also a way to accommodate the public more easily than mixing staff with them during a pandemic. Paneled exterior walls and modular infrastructure systems can be added to the building’s exteriors to expand and contract the sequence of entrances, allowing patients to wait within a modular space. Existing waiting areas should be modified and future waiting areas should be designed to meet the requirements of safe separation of six feet, with furniture quantities reduced and seating areas should be arranged in smaller groups to maintain distance.
- Flexibility and adaptability are the new normal. Developing patient rooms that can fold to different levels of intensity was once considered a luxury but is now a must. These flexible units are designed for the highest level of critical care with higher medicinal gases, more direct air and exhaust changes, and higher power supplies, all to meet the demands of critical care. The design of these flexible units must take into account the additional equipment needs that ventilators and bi-pap units bring to the design, and patient rooms must be sized to accommodate such equipment at the critical care level.
Wider aisles within these units should be considered to 12′-0″ to accommodate pre-temporary rooms and set up additional equipment. This comes with additional costs, and hospitals are weighing the pros and cons of the number of these types of units to be built.
- worker safety. Staff are a valuable resource. One way to keep them safe is to have proper supplies of PPE during health events for residents. Hospitals are reassessing the amount of storage needed and determining the appropriate levels of PPE to keep on hand for use during surges in current. Designers can help organizations find underutilized spaces on hospital campuses to help store supplies. Additional support spaces should be considered to allow staff to move from infectious locations to clean areas, take off PPE, shower, and change into uninfected clothing for travel home. Providing two sets of doors that normally remain open but can be closed to create room space prior to putting on/off PPE is another way to help keep employees safe and provide ease of use for PPE.
- Take advantage of technology. Better communication can help patients understand suggested treatments, and a caregiver can be a part of those discussions. The use of in-room voice-activated devices can allow nursing teams to complete tasks remotely. Technology can be leveraged to give patients the ability to control certain items such as window shades, lighting, temperature, and food ordering. Early in the pandemic and even now, hospitals are using artificial intelligence along with imaging and clinical data to analyze patients with coronavirus disease (COVID-19). Additionally, technology such as tablets and video conferencing capabilities in patient rooms can keep families and patients connected.
- Building a better infrastructure. Without the right building systems in place to support patient care, space availability doesn’t matter. Hospitals are now considering including increased building costs for energy, medical gases, clean air, and direct exhaust infrastructure to accommodate adaptable spaces for epidemic use. Creating a plan by designing adaptive patient care units along with backup infrastructure resources for these events can help make patient care during a pandemic more manageable. Older infrastructure should be considered for retrofit/replacement to accommodate the required air quality for infected patients.
futuristic healthcare design
In this evolving landscape, healthcare designers need to stay on the cutting edge of changes to combat this pandemic and the next. Proving and developing flexible and adaptable spaces in the future is the best way we can help healthcare organizations.
Catherine Gao, AIA, NCARB, Lean Six Sigma, is the Director of Health Facility Planning at FCA (New York). She can be reached at [email protected]. Jennifer Kinson, CHID, IIDA, NCIDQ, ASID, is responsible for interior design at FCA (Philadelphia). She can be reached at [email protected].