When the COVID-19 virus began spreading throughout the globe, the call to action rose up in the medical world — including those who work in healthcare facility design. Healthcare professionals did their best to prepare for an expected wave of patients in need of treatment, some requiring standard levels of care, while many others requiring intensive care, including intubations. By and large, the healthcare community in the United States rose up to meet the challenge.

Part of the way healthcare professionals prepared for what was coming, was by taking a hard look at the space they had available and how they can make better use of it to treat the maximum amount of patients.

Some communities converted convention centers into treatment facilities. In Arizona, a closed hospital, St. Luke’s Medical Center in Phoenix, was activated and utilized by the Army Corps of Engineers to ensure there were enough beds to meet the growing demand.

Valley architects sprung into action, as well, to help local facilities make the best use of their space.

Craig Passey
Steven Stack

“Here locally, our focus has been on helping Banner Health,” said Craig Passey, vice president and health studio leader for SmithGroup. “Banner has reached out to their architectural and engineering partners in the community to help maximize their ability to accommodate as many patients as possible.”

Passey said his firm helped Banner look into non-clinical spaces, such as conference rooms, dining areas or cafeterias, to see if they could be activated as treatment areas.

“The intent is to see how we can perhaps repurpose and maximize the number of beds they can get into their existing footprint,” Passey said.

SmithGroup was also part of a group of firms that were contacted by the City of Los Angeles mayors office. The group looked into converting the Los Angeles Convention Center into a space to treat patients if the need arose.

“The study was to understand how to work with the existing facilities and create a M.A.S.H. unit in the facility,” Passey said. “It yielded about 1,600 bays or stations. It also looks at some of the necessary support provisions that would be required.”

Passey agrees that the COVID-19 pandemic and the stress it put on healthcare facilities around the country will be something that healthcare design firms like his will be examining closely. AZRE Magazine reached out to Valley architecture firms to get their perspective on what the pandemic revealed as issues with healthcare facility design and what architects can do to make sure the facilities are better prepared for the next pandemic. Below are their answers.

AZRE: From a design and function standpoint, what are healthcare operators and engineers and designers learning about the limitations of their facilities during this pandemic?

Steven Stack, president of Devenney Group Ltd., Architects: Air distribution systems are not designed to provide the amount of negative pressure required to create isolation spaces for Covid-19 influx.

Negative pressure rooms are distributed across hospital units by design, to deal with the need across different clinical specialties. What is needed with Covid-19 is a large cohort of negative pressure rooms, not-distributed. Space for segregation of patients is not easily achieved with ICU space filling up quickly. Hospitals typically have a low number of ICU Beds compared to other bed types.

Some other facilities notes include:

* Extended staff amenities to accommodate caregivers on long shifts/ care givers from out of town, etc. such as things like dining spaces, respite spaces, sleep spaces.

* Overall available storage for additional required supplies due to increased required utilization.

* Need for triaging of different types of patients presenting – at more entry points than just the ED, where it is typically done with the desire to separate routine medical/surgical/maternity/trauma patients with possible Covid-19 patients.

* When looking at surge capacity – it is relatively easy to locate physical space – but more difficult to design needed privacy and creating a clinical environment (coreplast partitions/ICRA panels between temporary beds, adhesive floor protection over carpeted areas, power, med gas). 

* Patients housed in surge capacity spaces (offices, conference rooms – etc) still require adherence to HIPPA guidelines, also need bathroom facilities, power for devices, and to maintain minimal family contact. Amenities cannot be dismissed.

Ashley Mulhall, senior associate, high performance and sustainability leader at Orcutt | Winslow: The COVID-19 pandemic has exposed resiliency challenges that we have not seen before, most notably that our dependence on disposables is not effective during a crisis. We need to help facilities plan for in-house sterilization and material reuse beyond today’s current practices, which has implications to central sterilization, materials management, and operations. There is also a concern that all of the ramped-up cleaning will increase the speed in which resistant superbugs are created.

Carl Nelson, partner, healthcare leader at Orcutt | Winslow: Most facilities / organizations are realizing they are ill-prepared to handle the surges they are experiencing especially when it comes to converting existing spaces into temporary ones. Acuity has a tremendous impact on what spaces can be converted more readily than others. We are finding that it is difficult to convert large open areas such as conference and training rooms into high-acuity spaces. However, they can more easily be converted into non-COVID holding or observation units fairly quickly. Another major limiting factor is just availability of any unoccupied space. We are seeing the lack of space resulting in temporary “tent structures” or make-shift structures.

John Cantrell, principal, design leader at Orcutt | Winslow:  One of the biggest concerns of hospitals is managing the flow of visitors to the right service line for care. Hospital facilities managers and administrators are telling us that people infected with COVID-19 are showing up at any entrance to the campus and wandering around until they find someone to assist them. Two observations are being made regarding this: One is that medical campuses have too many uncontrolled access points; and two, the emergency department needs to be expanded virtually (think telemedicine) or via remote screening areas outside of the emergency department proper.

AZRE: To your knowledge, what are some creative ways healthcare facilities are currently adapting (or preparing to make adaptations) to accommodate the expected spike in patients?

A.M.: Most large facilities have in-house 3D printing capabilities and we are seeing these reconfigured to manage shortages of personal protection equipment (PPE) and other equipment such as ventilator parts. This out of the box thinking could transform supply chain going forward.

S.S.: Facilities are doing surge preparation that converts space in hospital not traditionally used for patient care such as cafeterias, conference rooms, waiting rooms, office, etc. Also, moving triage of patients to tents outside of emergency department. Current facility examples show parking lots and public spaces being empty and reducing overall parking need. This allows for patients to be “pre-screened” prior to entering the hospital and infecting others or getting infected.

Other things to consider include, utilization of concepts like demountable partitions could allow for quick reconfiguration of large open spaces and further embracing of modular style design that allows open spaces to be reconfigured.

J.C.: To comply with the Department of Health’s requirement to increase bed capacity by 25 percent, with a 50 percent capacity increase by late April, we’re working with Honor Health to assess their current facilities and specifically how we can repurpose underutilized space to accommodate general patient rooms.  This will free up beds within the hospital for Covid-19 patients. A rehab gym space has been identified at the North Mountain Campus of Honor Health that can fill the need to increase capacity to 50 percent.

Orcutt Winslow Associate, Jennifer Wilcynski, IIDA, NCIDQ, LEED-AP, EDAC, is leading a team of young architects and designers in the “Breaking Through Design Competition”, a national competition sponsored by Healthcare Design magazine to develop innovative and imaginative design ideas that will impact the healthcare industry. Utilizing one of the most common and available structures on urban hospital campuses – The Parking Garage. Her team seeks to “Un-park” the garage and look at design strategies that can positively impact the built environment of the urban hospital campus. Additionally, the team is looking to expand current Artificial Intelligence technologies for emergency triage solutions during this unprecedented time.

C.N.: Converting large areas of a certain non-related use such as parking structures into potential surge areas.  The challenge is infrastructure such as HVAC, Power and Plumbing.

AZRE: Once we are clear of this current crisis, what do you feel will be the first design change we will start seeing more of in healthcare facilities?

J.C.: One immediate change we expect to see is the concept of “Social Distancing” designed into all healthcare waiting areas. The days of one large waiting area may be a thing of the past.  Smaller enclave waiting space that separate sick from well visitors. Private spaces within emergency departments or doctors’ offices where you can wait as a care giver to a child or parent.  Last week I drove my wife to a cardiology appointment and was asked to wait outside because access has been limited patients only. A visit to the doctor should ease our stress level, not elevate stress levels. In communities with more temperate climates, outside “waiting rooms” with shade and enhanced natural ventilation could be a solution to expand and separate waiting areas.

Jennifer Wilcynski, interior designer at Orcutt | Winslow:  I believe one of the things that will come out of this pandemic is more physical barriers between our caregivers and the public. We are now seeing acrylic screens at the grocery store while we check out. We will need to consider the psychological impact of all involved – consider going from open nurse stations to enclosing them in “glass bubbles”. Do we prioritize our staff’s personal safety over open communication?  I think the answer to that is a resounding “YES!”  We are likely to see more ancillary pieces of furniture to house personal protection equipment (PPE) for the professional and public alike.  And, we’ll need a supply chain to ensure they are available to all our healthcare facilities.

A.M.:  Facilities who were forward thinking in terms of planning for resiliency, capacity, flexibility and a focus on staff well-being are reaping the benefits of their investments now.  Some of these nice -to-haves will make their way into code and FGI Guideline language.

C.N.: Perhaps to build-in more flexibility for accommodating more than one patient in a typical patient room. I also think that central warehouses for each system’s group of hospitals may become more prevalent to store surge supplies and be more efficient with distribution.

S.S.: Looking at opportunities to provide true isolation areas with negative pressure and possible even more departments focused on isolation and creating acuity adaptable space that can flex from medical surgical to ICU.

Recent conversion to private rooms limits the availability to utilize as semi private due to the limits of headwall med gases. Future facilities will look to provide ability to flex to 2-patient rooms.

Health systems will need to plan more strategically around which facilities in their systems should house “routine patient care” and which are equipped for disaster protocols. Patients could be better triaged across a healthcare system by allowing for routine day to day operations to function at a “non-disaster” facility.

There will be a higher focus on capabilities of the lab and enhancing and expanding capabilities in order to handle increased testing.

There will also be advance planning for future pandemic events.  This will allow facilities to have protocols, plans, supplies, etc. at the ready so that the response time is minimized.

Possible changes in code requirements in increments such as reduced space requirements in lower acuity areas.

Further enhanced technology includes: Wider telemedicine usage and increase of storage requirements for protective supplies, medical equipment, food, etc.

AZRE: How do you expect architects will approach coming up with creative solutions to facility issues that arose during this current pandemic?

S.S.: As a Joint Commission requirement, every hospital must regularly conduct a hazard vulnerability and risk assessment relative to their catchment area. This includes public health emergencies such a pandemic. There are three key essentials necessary for maintaining access to healthcare during disasters or emergencies: safeguarding human resources, maintaining business continuity and protecting physical resources. Required disaster planning includes emergency management training and coordination with local officials and first responders in a proactive, drill/planning scenario. We would expect architects and contractors to play a role in future drills and planning; in addition to seeing revisions made to individual healthcare facilities’ emergency management plans as a result of lessons learned through the Covid –19 pandemic. 

We will also assist with space planning to determine how many treatment areas or beds can be created in flex space. Designing bed layouts and addressing supply chain limitations.

I would also expect more engaging in strategic system wide and master campus planning efforts across a system to determine which facilities should be equipped for which level of disaster preparedness or surge capacity planning.

J.C.: There’s a lot of really interesting work being studied by non-architects related to the built environment that may have some merit in fighting future pandemics. One team of researchers at the University of Chicago’s Center for Care and Discovery, overseen by Jack Gilbert, Microbial Researcher and Director of the Microbiome Center at the University of Chicago, is working on using microorganisms to customize our spaces with the right microbes. Researchers have catalogued the developing microbiome of a newborn baby. Gilbert has, for the first time, catalogued the developing microbiome of a newborn building. His team is analyzing the data to work out how the presence of humans has changed the building’s microbial character and whether those environmental microbes have flowed back into the occupants. I realize that this technology and research is “out there” but I envision a day where architects and interior designers begin to collaborate with micro-biologists to design hospitals to infuse them with good microbes that promote health and wellness and possibly fighting off bacterial that might be part of next, or this, pandemic.

Architects and designers generally apply their skill sets to solving existing problems that they can see, when in fact, we need to expand our design process’ to look ahead and predict problems we need to solve before they happen.  In a Design Intelligence article by Michael Lefevre on Foresight he writes: “Foresight is intentional and can be developed as a form of intuition and data-enriched visibility. Those who have it, start by pausing to look.  Where are the beneficial Black Swans of our industry – and who can see them coming?” He goes on to suggest that by pooling our intelligence to see collectively can we plan for unpredictability. The message is clear – to solve these problems and those in the future it will take the collective thinking of healthcare providers, architects, designers, medical simulation modelers, construction experts and manufacturing industries to come together and to look ahead. To see the next Black Swan coming we must be looking.

At Orcutt | Winslow, our longstanding relationships with local and national healthcare providers translates into years of institutional data that we’ve collected and can quickly be provided to our medical simulation experts and hospital partners, to allow then to make informed decisions moving forward.

C.N.: There will be a flood of talks, pod casts, papers and conference presentations around this subject matter. In a way, healthcare architecture has been searching for the next trend. Previous trends include BIM, Evidence Based Design, LEAN / IPD and most recently Behavioral Health. You will find that every healthcare architect will likely proport that they have been involved with surge projects and will find angles to leverage that experience. What we really need to focus on is how we take the lessons learned and apply them to future events AND other areas within healthcare design. One reality we are seeing is that healthcare providers are NOT deploying many of their surge plans since reimbursement will not be 100 percent and in some cases none at all, AND they are creating and monitoring their own surge models (in addition to state and federal government) to predict how much surge and at what acuity level may be needed.  As usual the dollars will have a big impact on what can actually be accomplished. I just hope we don’t lose sight of these important lessons in the future.

A.M.: The innovative responses to this crisis are inspiring – from rapid transformation of hotels and schools to patient care areas and the fast construction of mobile units using shipping containers. This crisis is permeating pre-existing silos because everyone is being impacted.