COVID-19 and how it is Shaping the Future of Healthcare Design

Although we have been captivated by the media’s coverage of COVID-19 and how it has affected and devastated countries around the world like Italy and China, we still couldn’t quite predict just how fast moving this deadly and truly unforgiving virus would be when it arrived on U.S. soil. We didn’t yet realize our innocent ignorance about how it spreads, how vulnerable we, as a communal society would be, and how this would gravely affect the healthcare systems in our towns and cities. The emergence of the COVID-19 threat has not only brought a trail of devastating lessons learned but has also shown the resilience of the human spirit and the strength and heart of every hospital care giver. We are witnessing extreme generosity and tenacity in the face of adversity.

As we continue to fight this pandemic, we are accruing several “lessons learned” that will affect the way we plan, design, renovate and build for the future of healthcare. 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 threatening existing silos because everyone is being impacted.

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 them to make informed decisions moving forward.

Foresight in Design – Flexible and Adaptable Space
The rapidly changing needs we are seeing prove the importance of designing buildings to have alternate lives beyond their original intent. Two months into this crisis, it is apparent that our buildings are becoming barriers to the rapid transformation needed today. This changes everything about how we design going forward.

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 only 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, engineers, 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.

How do we plan for unpredictability? Perhaps, building-in more flexibility for accommodating more than one patient in a typical patient room. It is becoming more common to see standard-Issue hospital patient rooms being more readily converted into a new type of universal care / ICU Room that can be dedicated to treating various acuities by floor. Separating acuity by floor can make the zoning of air balance and filtration much more efficient and easier to implement quickly.

With patient bed expansion requirements from our governments, flexible spaces will be part of every facilities’ planning strategies. From where a tent can be erected to where a mobile unit can be delivered. Additionally, each healthcare system will be thinking creatively about their current real estate outside of the hospital itself; including ancillary buildings, nearby hotels, clinic spaces, parking structures, etc. (These will all be used during surge planning). Decisions will need to be made regarding what spaces can be converted to house certain acuity levels.

Conversion of Existing Spaces / Limitations in the Face of a Pandemic
It’s hard to imagine that Healthcare, as one of, if not the most regulated industries in the country was not positioned to cope with this current pandemic. Regulations never took into account the sheer magnitude.

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 areas of a certain non-related use such as parking structures, conference rooms, and lunchrooms to be quickly converted to high acuity treatment spaces/potential surge areas. The challenge is infrastructure such as HVAC, Power and Plumbing. 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.

Specifically to Arizona, to comply with the Department of Health’s requirement to increase bed capacity by 25% as early as April 10th , with a 50% capacity increase by late April, we were working with HonorHealth to assess their current facilities (system-wide) and specifically how we can repurpose underutilized space to accommodate patient care areas. This will free up beds within the Hospital for COVID-19 patients. Within the last five days, 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%.

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.

Managing Hospital/Patient Flow
One of the biggest concerns of hospitals is managing the flow of visitors to the right service line for care. Traditionally the Emergency Department has been seen as the Front Door to the hospital where patients present, and triage and assessment takes place. 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 to be made:

Social Distancing in Waiting Room Design and the Patient Experience
A visit to the doctor should ease our stress level, not elevate stress levels.
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. We will see smaller enclave waiting spaces that separate sick from well visitors and private spaces within emergency departments or doctors’ offices where you can wait as a care giver to a child or parent. 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.

We believe that another element that will come out of this pandemic is the concept of 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? We think the answer to that is a resounding “YES!”

A downside of this ‘physical barrier ‘discussion is the erosion of the ‘compassionate care’ environment that has been a defining aspect of the nursing profession. Innovation will hopefully evolve ways that we can provide these separations with low-volume air curtains or other technologies that will reduce the number of physical barriers, while keeping patients & staff safe.

Additionally, technology will play a role in solving the waiting room dilemma. Digital patient management tools are enabling patients to check in online, real-time feedback via mobile devices can have the patient arrive when the medical team is ready for them, and electronic bill paying avoids gatherings at check-out areas. As a result, waiting spaces become ‘pause spaces’, reducing the crowded waiting room problem.

Finally, while RTLS (real-time locating system) technology for patients is in its infancy, we believe that will become mainstreamed quickly. The ability to track all patient locations within a patient care environment will give staff an understanding of where every patient is and should be, alleviating unplanned gatherings of patients and helping with distancing

Sustainability and the Supply Chain
We’ll need a supply chain to ensure personal protection equipment (PPE) is available to all our healthcare facilities. Central warehouses for each system’s group of hospitals may become more prevalent to store surge supplies and be more efficient with distribution. 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.

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.

Creative solutions to facility issues that have arisen during this pandemic.
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. We realize that this technology and research is “out there” but we 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 bacteria that might be part of next, or this, pandemic.

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.

Our Focus Must Be Lessons Learned
There is 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% 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. We just hope we don’t lose sight of these important lessons in the future.

Carl Nelson, AIA NCARB LEED AP is a Managing Partner at Orcutt | Winslow with over 30 years of experience. He has established a national healthcare planning and design presence for the firm and focuses on firm-wide strategies for innovation and client excellence.

Chuck Hill is a Healthcare Studio Leader at Orcutt | Winslow who combines over 40 years of experience dedicated to architectural design with his passion for developing innovative ways to improve the healthcare experience for staff, patients and their families. He provides an integral level of team management and a fresh perspective for a project’s scope while monitoring team resources and the relationship of project budget, schedule and production.

John Cantrell, AIA is a Principal and Director of Design at Orcutt | Winslow, and instrumental in leading the office in developing Experiential Design strategies that push the envelope of current design thinking through every activity associated with project engagement.

Ashley Mulhall, AIA NCARB, LEED-AP BD+C WELL AP, EDAC: with over 15 years of design experience, Ashley currently leads High-Performance Building and Sustainable Design at Orcutt | Winslow and coordinates the review and implementation of sustainable strategies and practices to ensure every project achieves a high level of WELL, sustainability and efficiency.

Jennifer Wilcynski, IIDA, NCIDQ, LEED-AP, EDAC is a NCIDQ and EDAC certified Interior Designer and Associate at Orcutt | Winslow with over 18 years in the profession who creates exceptional experiences for patients, families and staff in healthcare spaces.