Bryan Langlands

Bryan Langlands

Principal, NBBJ
Bryan is an accomplished healthcare programmer, planner and designer of academic medical centers, specialty centers and community hospitals. He is currently a steering committee member of the Facility Guidelines Institute (FGI) 2022 Health Guidelines Revision as well as chair of the 2022 Beyond Fundamentals Oversight Committee. In 2018, Bryan was named Team MVP as part of Healthcare Design’s Top 10 awards for his work with FGI and on low-acuity patient treatment stations in emergency departments.

How to Convert College Dorms to Support the Fight Against Coronavirus

With Hospital Space at a Premium, Eight Strategies to Adapt University Campuses

March 25, 2020

Principal, NBBJ

Editor’s note: Our healthcare clients are on the front lines of the coronavirus crisis. We seek to support them as they courageously care for the sick. Here are some thoughts and observations which we would like to contribute to the discussions that are going on during the COVID-19 pandemic. From all of us at NBBJ to the many doctors, nurses and support staff in hospitals and clinics, a heartfelt thank you.

This post was co-authored by Bryan Langlands, Cathy Bell and Paula Buick.

 

With the number of global coronavirus cases increasing each day, health centers are more burdened than ever before, witnessing severe bed shortages for critically-ill patients. At the same time, housing at many higher education institutions now stands mostly vacant — with hundreds of thousands of students home for social distancing and instruction now delivered online.

There are a lot of discussions about using student dormitories to help assist with the COVID-19 pandemic. In New York, Gov. Andrew Cuomo has announced that the Army Corps of Engineers has selected sites for temporary hospitals on college campuses to increase bed capacity (and the National Guard, overseen by the Federal Emergency Management Agency (FEMA), is building four temporary hospitals in the Javits Center). Washington State and California are exploring options too. While student dormitories are well-suited to certain alternate healthcare uses — from housing clinical staff to treating low-acuity patients — there are important elements to consider when exploring how to convert them for coronavirus treatment, such as building codes and frameworks. Here are a few takeaways.

 

Potential Uses for Dorms During the Coronavirus Epidemic

Monitor “well” people rather than sick patients. Most dormitories don’t have the required medical infrastructure in place — such as appropriate electrical power and emergency backup, and medical gases for an intensive level of care. Instead, they may be better suited to serve as places for healthcare workers to monitor otherwise-stable, quarantined individuals that require isolation so they can be observed and not infect others. In New York, SUNY is currently quarantining students and staff returning from study abroad programs in designated dorms. In addition, to help free up beds in hospitals for COVID-19 patients, dorms could provide space for rehab or post-surgery physical therapy patients.

Expand screening centers. To minimize coronavirus cases in the ER or even a primary care clinic, student dorms could serve as a first point of contact for coronavirus screening, helping supplement drive-through testing and out-of-hospital triage tents. This would help alleviate the volume of patients showing up at hospitals, which should be used for the sickest of patients.

Offer housing for healthcare workers. Due to the virulent nature of the coronavirus, many healthcare workers don’t feel comfortable going back home to their families or roommates in the evening and need a nearby place to rest between shifts. Student dormitories could provide a safe and convenient option.

Provide stable shelter for the homeless. Over half a million people in the U.S. are homeless. California Gov. Gavin Newsom has dedicated $50 million in funding to lease hotels, motels and other facilities for social distancing and quarantines. Dorms, like hotels and motels, can be converted into temporary housing for the unsheltered, where they can receive coronavirus screenings, stay for a period of time, sleep, shower, receive meals, and have access to other health and public services.

 

Key Elements to Keep in Mind Regardless of Use

Consider proximity to adjacent medical services. Is the available dormitory close to a hospital or medical center? Location is important, given staff availability and supplies. Dispersing staff to ultra-remote areas could strain already burdened healthcare systems.

Address building guidelines and codes. Examine the approval and permit process already in place, and determine what else may be needed to successfully deliver the project. For instance, all hospitals overseen by the Massachusetts Department of Public Health require beds located in alternative acute inpatient areas to be spaced at least six feet apart from one another, to contain medical gases (an oxygen outlet and vacuum outlet per bed) and to provide accessible hand washing sinks and privacy partitions.

Develop a systematic framework for conversions. The Army Corps of Engineers is refining a “cookbook of models” — with blueprints recently approved by FEMA — to convert alternative buildings for healthcare use in under a month. To determine a facility’s readiness, the first step is to conduct walk-throughs to assess existing layout and infrastructure conditions such as plumbing, electricity and ventilation. It’s important to evaluate a dorm room’s ability to be isolated and to create an environment required to keep the coronavirus from spreading. This includes: the ability to use self-contained air conditioning units to create “negative pressure rooms”; the ability to maintain the negative pressure seal at each room’s entrance by covering it with plastic and a zipper; and the ability to have a nurses’ station located in the hallways. Another key element to consider is the facility’s accessibility: Is the entry level floor at-grade, or is there a ramp wide enough to take a bed or gurney? Are the elevators, and doors to rooms, sized for bed and equipment movement?

Create a strategy for the short term and long term. It’s critical to address the current situation while planning for the future. Establish a rigorous strategy to convert the dormitories for healthcare use as well as protocols for transitioning them back to student housing. Will there be a residual stigma that will need to be addressed?

While the decision to temporarily convert student dorms is complex and should be taken with care, time is of the essence as healthcare facilities face extreme strain. Although there is no “one size fits all” approach, repurposing student housing can offer much-needed space and other resources to help alleviate these pressures.

 

How are you and your healthcare organization dealing with the coronavirus? We’d like to hear from you. Drop us a line at socialmedia@nbbj.com.

Banner image courtesy Scott Web/Pexels.

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How to Find Space — and Fast — for a Surge in Coronavirus Patients

Considerations for Adapting Hospital Space and Keeping Patients Safe

March 23, 2020

Principal, NBBJ

Editor’s note: Our healthcare clients are on the front lines of the coronavirus crisis. We seek to support them as they courageously care for the sick. So we’re posting design ideas based on work with them, in the hope that we can contribute from our base of expertise to help combat the epidemic. From all of us at NBBJ to the many doctors, nurses and support staff in hospitals and clinics, thank you from the bottom of our hearts.

This post was co-authored by Bryan Langlands and Sarah Markovitz.

 

As America’s hospitals grapple with the coronavirus (COVID-19) pandemic, they are rapidly considering ways to retrofit existing facilities to cope with an influx of cases. And new analysis out of Harvard University suggests that most parts of the US are under-resourced in the number of hospital beds — particularly ICUs — needed if the coronavirus continues to spread and escalate as projected.

Here are near-term solutions to create appropriate space and add additional treatment areas to prepare for the challenge.

Allow patients to bypass emergency rooms.

A number of healthcare organizations are looking to divert patients from entering the emergency department altogether while still providing treatment.  For those patients arriving to the emergency department requiring diagnosis and simple treatment, hospitals are coming up with ways to do all of this proximate to — but not directly within — the emergency department.  Temporary tent structures, mobile units, or partitioning of waiting areas for treatment are all potential solutions for hospitals.

Once in the emergency department, due to the highly transferable nature of the coronavirus, hospitals should find ways to spatially separate those patients presenting with virus symptoms from those coming in for other emergency conditions. One New York City hospital did this by repurposing its pediatric emergency area to focus exclusively on coronavirus cases.

Relatedly, some children’s hospitals are expanding the age range of patients that they will care for to free up additional adult care beds at general hospitals. These spaces are also well-suited to be repurposed for coronavirus care since they’re already designed with designated arrival and treatment zones to accommodate children with contagious conditions.

Repurpose other hospital room types into ICUs.

As some U.S. hospitals start to limit non-emergency and elective surgical procedures, enclosed patient care spaces within post-anesthesia care units (PACUs) and recovery rooms can be converted into ICU environments to accommodate additional patients with severe cases. If an open PACU environment exists, then the entire space would need to be dedicated exclusively to a COVID-19 patient care ward.

For hospitals faced with quickly and effectively transitioning these spaces, there are four primary spatial and clinical considerations:

Ensure rooms are properly equipped. Any room being treated as an ICU will need piped medical gases (commonly found in PACUs), oxygen, medical air and vacuum supply, both power and emergency power backup, and data. The infrastructure requirements for an ICU are similar to what is provided at PACU positions.

Avoid mixed modeling. Where possible, hospitals should ensure, via signage, physical barriers, and/or operational protocols, that repurposed wards are distinctly dedicated to coronavirus treatment in order to eliminate the possibility of exposure to other patients.

Clear hallways and provide PPE areas. For wards being converted to coronavirus response zones, hospitals will need to ensure clear and segregated hallways and corridors, limiting who is able to pass through. Each enclosed room where the patient is on isolation should be equipped with a cart outside, stocked with appropriate personal protective equipment (PPE) for staff to change into and out of before entering and exiting.

Create necessary barriers and protective measures. Hospital leadership will need to work closely with construction partners and mechanical engineers to balance, when possible, the unit’s airflow system. With the right infrastructure, the mechanical systems can help create infection control barriers and ensure negative air pressurization of the area and treatment rooms. If the existing mechanical system cannot provide the negative air pressurization and 100% exhaust to the exterior, strategies could be implemented similar to the type of configuration utilized when doing construction and renovation in an existing, operational healthcare environment.

For any repurposed rooms in close proximity to operating surgical suites, additional protective measures will be needed. These spaces typically operate as positive air flow rooms, requiring construction barriers and an additional antechamber or buffer zone. Additional security measures and access control can be introduced which restrict access to prevent non-surgical staff from entering.

Each hospital will have to consider these measures in relation to their own unique floorplans, layouts and infrastructure. And of course ensuring an adequate supply of appropriate hospital beds is just one part of the solution, alongside staffing needs and flexibility, and appropriate supply of equipment and protective gear. Integrated teams should also consult closely with any authority having jurisdiction (AHJ) in exploring these ideas.

 

How are you and your healthcare organization dealing with the coronavirus? We’d like to hear from you. Drop us a line at socialmedia@nbbj.com.

Banner image photography by Benjamin Benschneider.

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Three Ways of Reimagining the Emergency Department

Ideas for Shaping the Emergency Department of the Future

February 12, 2019

Principal, NBBJ

Editor’s Note: This post is adapted from a white paper co-authored by Bryan Langlands and Durell Coleman, Founder/CEO of DC Design, and originally published by the Facility Guidelines Institute (FGI). The white paper is based on the “Reimaging the ED” workshop sponsored by FGI and the American College of Emergency Physicians (ACEP) and held at the 2017 Healthcare Facilities Symposium & Expo in Austin, TX, where more than 100 ED clinicians, design professionals and students gathered.

Today in the United States, nearly 50 percent of all hospital care begins in the emergency department (ED) and, over the last 20 years, ED patient volume has increased by 23 percent as many Americans use the ED to access primary care services. Many factors have contributed to these trends, including:

  • The aging of the baby boomer generation
  • Increased longevity of people with chronic diseases
  • Gaps in provision of care for behavioral health patients
  • Limited operating hours of primary care providers
  • Lack of affordable insurance and other issues affecting individual access to medical care
  • Requirement of the Emergency Medical Treatment and Labor Act (EMTALA) for EDs to treat everyone, whether they have insurance or not

While the U.S. health care system struggles to determine how to address these difficult and complex issues, there are changes that can be implemented now to improve the function and flow of emergency department services and facilitate quality patient care: by (1) improving arrival and front-end operations, (2) reducing patient length of stay, and (3) improving the experience of behavioral health patients.

 

(1) Improve arrival and front-end operations with technology.

Technology could be deployed to make patient arrival, sorting, and waiting processes more efficient. One idea: providing a registration kiosk for low-acuity patients. Another idea is a vitals-monitoring bracelet that could be used to assess and monitor patients in the waiting area. Such approaches could result in reduced stress and better flow for triage and front-end operations.

 

(2) Reduce low-acuity patients’ length of stay.

A significant problem is the treatment of low-acuity, non-emergency patients in spaces designed for patients who require a bed. Some solutions: smaller treatment spaces for these “vertical” patients, or treatment rooms that could easily and quickly be converted to hold multiple low-acuity patients during peak hours. Such spaces would speed up delivery of care for low-acuity patients and reduce the amount of time they — and consequently all patients — spend in the ED.

As one way to identify these low-acuity patients, the ED could be zoned by Emergency Severity Index (ESI) level. Creating ESI zones would support more flexible and efficient use of space and could decrease patient waiting times. Each area in the ED would be designed with patient care stations sized appropriately for the type of patient seen there.

 

(3) Create spaces for behavioral health patients.

There are many concerns surrounding behavioral health services provided in the ED setting, including the tendency to hold these patients in the ED for two to three days before placement in an inpatient unit or transfer to a psychiatric hospital. Spaces are needed that better suit this patient population. Because the ED is not specifically designed to provide care for the behavioral health population and the typical patient stays longer and requires different attention than typical ED patients, the flow and throughput of the entire emergency department is negatively affected when suitable behavioral health facilities are not provided.

 

It is important to remember the ED is not a “place” but a “process,” a point that underscores that many problems seen in EDs are the result of operational processes rather than design issues. Further, the primary factors of many problems are neither design nor operational, but issues that result from demographic changes, behavioral health and insurance deficiencies, and EMTALA requirements. For this reason, quite a few problems might not require specialty operational or design solutions if the overall health care system were doing a better job of addressing the larger issues that bring many patients to the ED.

Nonetheless, it is an important first step when health care organizations and designers work together to address operational and design problems through careful project planning.

Banner image courtesy of Frank Oudeman/NBBJ.

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