Having advised many healthcare organizations in their preparations for the COVID pandemic, we recently brainstormed with our design partners in architecture and engineering to capture lessons learned, what we would do differently in facility design for the future and what we think our clients should be thinking about next.
As healthcare organizations across the U.S. worked to rapidly increase bed capacity in response to COVID-19, we found many were not aware of what resources they actually had, which patient care areas could be used for expanded bed needs and how to evaluate appropriate uses. Each hospital design and situation was unique and this affected the approach taken when assessing, adjusting, and modifying health facilities and their infrastructure.
In the midst of the pandemic there is little time to implement or modify an approach when the facility is at maximum capacity. If you’ve modified your facility and operations to accommodate the first wave of infectious patients, what should you be doing now to prepare to return to a new normal, knowing there will likely be a second wave?
Read on for actionable steps and strategies to consider in the next six months.
Step 1: Recommissioning
- As you prepare to restart elective procedures, think about what will make the public comfortable going to the hospital again. Patients will feel uneasy or fearful until there is effective medical treatment and a vaccine. In the same way mechanical systems are commissioned, is there a re-certification needed to tell the public that a hospital is a safe place to go for care?
- CMS 1135 waivers had a 45-day code re-compliance window, following non-code compliant modification in response to the COVID-19 pandemic. Is there a third- party verification needed as things move forward? Engage your architect and/or engineer to create a checklist to get back to compliance as a healthcare delivery system.
- Many healthcare facilities have modified their mechanical systems for the pandemic in a variety of ways, changing the pressurization and air changes in response to the wave of infectious patients. Now is the time for recommissioning and rebalancing to get back into a proper healthcare environment.
- As elective procedures begin again, there will be a significant increase in pre-admission COVID-19 testing for patients and providers and staff. Consider where and how will that best occur in your facilities or off-campus. Healthcare systems will want to move quickly to increase revenue but need to do this thoughtfully and with a high level of safety for all.
Step 2: Reevaluating
What facility infrastructure upgrades should be prioritized as funds become available? Here are a few we are thinking about:
- What kind of air cleaning treatment modifications can you do now to provide more safety and flexibility in the future? The industry is leaning towards HEPA filtration – we saw shortages of filters in this crisis. What are other considerations? Bi-polar ionization is another cost-effective technology. Combined with HEPA filters, this was a very effective strategy in combatting H1N1. Another effective solution is UV lighting with slow air flow (the slower the air, the more effective). These systems can be further explored: while considering UV safety, can these lights be mounted high on the wall in a patient room to kill contaminants in the upper air?
- Medical air is not required in most patient care areas, but it was needed in surge areas for the pandemic. Evaluate whether you should add medical air to other patient care areas for future needs.
- Waiting rooms in emergency and imaging departments are required to be fully exhausted to the exterior, but no other congregating areas are. Consider exhausting air in entry lobbies and/or general waiting areas. Determine if any areas should continue to be exhausted through the next winter now, so there is enough time to make the required modifications.
- You are likely already considering how your expanding non-infectious patient volume and their caregivers will be protected within your facility. Is there value in instituting interior one-way traffic or limiting access to certain areas, as we have seen many grocery stores do during this pandemic, to reduce likeliness of infectious contamination and make social distancing easier?
- Evaluate your furnishings and interior finishes, especially in patient care areas to ensure they are not creating an infection control issue through deterioration from use or harsh cleaning chemicals. And if you are seeing a faded finish or finding sticky residue on any surface, review your environmental services cleaning protocol to be sure it remains appropriate.
Step 3: Rethinking
How can we increase flexibility in healthcare planning and infrastructure systems design to make adaptation for future pandemic scenarios more effective and efficient?
- Personal Protective Equipment (PPE) is now part of our collective awareness as it’s never been before. The donning and doffing of PPE and storage takes up space. How do we better accommodate this critical activity in the future? Can we flex waiting areas in time of pandemics to create a better PPE process including handwashing?
- If you are engaging in a renovation or a new design project, consider creating all acuity adaptable patient bedrooms designed to ICU standards for electrical needs, med-gases and air changes. The biggest difference in design is the location of the toilet room within the patient bedroom. Outboard and interlinking toilet options are best for an ICU environment, providing the most patient visualization from the nursing perspective. Patient surveys and focus groups tell us that the sicker the patient, the less concerned they and their family are about privacy and the more they prioritize observation by staff.
- What should evolve in ICU design? One finding is that many medical air systems (typically required only in ICUs to support ventilators and other medical equipment) historically have been designed to provide a lower percentage of rooms with medical air at one time, because that is the typical scenario. Plan for future use of 100+% of ICU rooms to provide medical air and use larger piping to exponentially increase your medical air capacity available.
- Traditionally engineers have sized air returns smaller than supply (to create positive pressure), but we wouldn’t recommend this in the future. On economizer mode, when using 100% outside air (as many systems currently are, to create negative pressure and exhaust infectious contaminants), some areas are not achieving negative air pressure. Increase the size of return ductwork and use a bigger fan on the return to provide for greater flexibility to modify your system in the future.
- We saw the challenges that lack of supply and equipment stockpiling created for healthcare facilities with COVID-19. This is the time to take a hard look at your supply chain. The cost reduction just-in-time delivery strategy so prevalent in lean thinking of recent decades could become a thing of the past.
- One thing we have all learned from the pandemic, is how much we can do virtually. As face-to-face interactions are rethought in nearly every realm in healthcare, how can you prepare for a big shift in the future to telehealth visits and remote work? Is your IT infrastructure up to this challenge? From a clinical workspace perspective telehealth only requires a small workstation for a provider with a backdrop and acoustics that reinforce patient privacy. And if they haven’t already gone this route, many non-clinical functions currently housed on healthcare campuses are candidates for off site remote work or work from home. This will help reduce operational costs and future campus size requirements.
Our lessons learned from the COVID crisis of 2020 will continue to evolve and expand over time. Future designs for health will need to be more flexible to support future pandemic scenarios as well as our new normal. Now is the time for innovative thinking. How can we help?