By Chris McQuillan, B.Arch., FRAIC, OAA, LEED AP
We are living in a time when deaths from conflict or communicable diseases such as small pox, measles and polio are at historic lows, so our focus on health risks tend to be limited to lifestyle ailments or weathering the annual flu. But this changed dramatically when the COVID-19 outbreak began a few months ago. A quick study of historic data shows that over the last 500 years, epidemics account for a death rate three to seven times higher than that of conflict. With the advent of modern medicine, our solutions 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. However, none of these challenges is as great as the one posed by the current global pandemic.
SARS, MERS and H1N1 have previously challenged the best healthcare and medicine ever created. Lessons were learnt from these situations. Hospital design has evolved and this is particularly evident in those locales that have been hardest hit. These lessons are important to help our healthcare systems respond to COVID-19—and future similar situations. Some of the essential innovations and lessons learnt so far in keeping us safer today are detailed here below.
Infection studies have long shown that person-to-person contact and contact with surfaces contaminated with droplets are common ways to transmit microbes and viruses. Prior to the SARS pandemic, standards for hand-hygiene stations in hospital were inconsistent and often not applied. A key innovation was a codified standard wherein every environment that involves patient-caregiver contact is equipped with a conveniently placed hand hygiene station. Ideally, this should be a dedicated hand-washing sink, but if not feasible, an alcohol-based hand rub will do. Almost all hospital entrances have now been equipped with a hand sanitiser.
USE OF MATERIALS
Experience with highly contagious diseases has placed new emphasis on the ability to disinfect areas of the hospital. Science has studied the effects of using various building materials and how these materials inter-react with contagion and cleaning. Research findings have led to a significant change in most of the materials used in the interior finishing and furnishing of healthcare facilities. We now mostly use non-porous materials with minimised/shallow joints, shelves and recesses that are easy to clean. We use technologies such as copper/silver ion coatings and UV light sources to sanitise surfaces.
Prior to SARS, hospitals had little physical infrastructure to isolate patients suffering from respiratory syndromes. During that crisis, many facilities constructed ad-hoc air-handling systems or re-balanced building infrastructure to provide local or zoned isolation areas, so that contaminated areas or individuals could be separated from uncontaminated ones. In subsequent years, in all new hospitals, every department is equipped with isolation rooms, which usually takes up 5 to 10 per cent of the spaces. Hospitals now are also able to separate zones to give caregivers a variety of options to contain infection.
SINGLE BEDROOMS/TREATMENT BAYS
For anyone entering a hospital and wondering if it was 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 normal for emergency departments to separate treatment bays with curtains. Similarly, inpatient units were often designed with semi-private rooms and even four-bed wards. Single-bed rooms were few and reserved for those with a higher purchasing power. It quickly became apparent that patient bedrooms and treatment areas needed to be designed and built to allow isolation. The rooms should be negatively pressurised relative to the corridors. Thresholds should provide ideal areas for personal protective equipment protocols. Decentralised nursing stations should be designed in a way that support local access to patient data and maintain clear view of the corridors so that nurses can see patients without having to enter the room. With such a large number of curtained cubicles and shared inpatient beds in older hospitals, the isolation capacity was actually 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 a healthcare facility. Due to higher awareness of how the diseases were transmitted, routes for patients, supplies and equipment to and from treatment areas were kept separate from others. In many older facilities, department floor areas often had a single point of access. Flow separation was not a priority or it was postponed until after business hours. In a pandemic scenario, these options are not available. More recent planning aims to facilitate treatments more effectively. Clean areas are separated from soiled areas. The depth of ingress of ‘dirty’ flows into departments is minimised. Isolation spaces are located at departmental perimeters. Access for staff and supplies are separated from patients and families. Diversity of access is provided so that portions of some departments can be independently accessed to treat different patient populations.
ACCESS AND SCREENING
Access points to healthcare facilities will have to change if screening is to be done to everyone entering the buildings. To minimise the spread of contagious diseases such as COVID-19, in addition to heightened security, the number of access points should be reduced and separation of the different flows—for patients, staff, wastes, supplies—should be enhanced. In old hospital designs, the boundaries between public and functional areas and access points were not clearly defined—and this should be changed. In addition, the footprint of access points should also be enhanced to accommodate screening stations and there should be a space for carers to put on and take off personal protective equipment.
If needed, there should also be an examination of other risks to determine if the provision of additional outdoor space is needed. Such spaces might be created by constructing temporary structures and services for physical decontamination. All of these interventions will lend 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, 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 have all raised questions about how 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.
For the next frontier, what is needed is the availability of consumable supplies and key equipment such as ventilators. This is not a physical challenge but a logistical one. Healthcare already represents a high percentage of GDP in many advanced nations. More substantial investment in healthcare infrastructure should not be too much of a challenge. Our greatest opportunity to improve our response lies in harnessing other assets in our built environment. The lessons learnt 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.
– Construction+ Online
About the author:
Chris McQuillan has been in the healthcare design industry for more than 20 years and has accumulated rich experience in healthcare, behavioral health, bio-medical research, facility and function planning, as well as project feasibility study. In 2012, McQuillan joined B+H Architects—a global, award-winning architecture, interior design, planning, landscape architecture and strategic consulting firm—and has since led his teams to deliver a range of transformative healthcare solutions that positively impact people, the community and the environment. To date, B+H has delivered over 90 healthcare projects across 31 countries and over 1 million square metres of new and renovated healthcare work. McQuillan believes that high-quality design for healthcare service originates from the know-how of providing support to others and the close cooperation with users, medical staff, patients as well as other stakeholders to create medical facilities that improve wellness and healing.