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 Reduce Social Isolation for Healthcare Workers and Patients During the Coronavirus Pandemic

September 1, 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 initially appeared on Forbes. It was co-authored by Bryan Langlands and Teri Oelrich.

 

COVID-19 increases social isolation for almost everyone, but especially for caregivers on the frontlines and patients in hospitals. This is in part due to critical infection prevention systems, safety protocols and social distancing measures, such as multiple layers of PPE, single-patient isolation rooms and no-visitor policies.

Studies reveal isolation, which can lead to loneliness, can both increase anxiety and depression as well lower trust, energy and social engagement. Yet despite countless conversations with healthcare workers on the front lines — from nurses to pastoral care — who say social isolation is a challenge for both caregivers and patients, there is hope. Below are key insights from these discussions, as well as strategies to create environments that ease isolation.

How to combat the effects of isolation

Because of the increased isolation due to COVID-19, the pandemic takes a toll on both extroverted and introverted staff. Extroverted staff that gain energy from social interactions may have a more difficult time than introverts, who typically enjoy more time alone. Yet while it may be easier for introverts to cope in the short term, introverts need social time as well in addition to downtime that’s not just with a patient. For example, in conversations with frontline workers, they report missing  the after-work informal socialization at restaurants and bars. How can caregivers be connected to others so they’re not fighting the battle by themselves? Here are a few strategies that may help.

Offer space for enhanced communication

Studies show that body language may account for up to 65% of all communication or more, so it’s crucial to employ innovative ways to communicate. Masks and PPE hide dialogue, greetings and facial cues, which are all crucial ways to convey not just critical patient information, but also ideas, feelings and beliefs.

Clinical staff who work with patients on isolation could use glass doors to communicate with colleagues outside the room by writing notes to each other on the transparent surface. In addition, digital and analogue message walls can provide opportunities for staff to share more informal, personal notes of encouragement that can be pushed from their smartphone or posted via sticky notes. Furthermore, nursing units with decentralized nurse stations could help minimize social isolation.

Boost opportunities to personally connect

It’s important for caregivers to share experiences and connect personally outside of work tasks, as well as celebrate milestones and work successes. Staff potlucks, birthdays and holiday celebrations are a mainstay on nursing units, and an important way for staff to interact and connect with one another.

In feedback from frontline caregivers, there are valuable opportunities to provide better break rooms. These areas could feature operable windows for fresh air, sunlight, and views of green plants, to not only create a more pleasant space for socializing, but to help boost mood, improve cognition and decrease stress. The size of break rooms should also be considered if social distancing is required when eating because a room which previously held 10-12 staff might only hold 3-4 now.

In addition, stairwells and the ends of corridors could serve as places to catch up with colleagues, and instead of places solely dedicated to circulation, they could also serve as destinations. Feedback from staff who work in hospitals where staircases are along glass perimeters of a building tell us that they become a “found” place for restorative respite, to take a moment to pause or to encourage exercise. Staircases with daylight and generous width and landings are highly popular with staff as a place to take phone calls, meet with a colleague, take a “time out” moment, and for some, to even have lunch.

Expansive windows with views, soft bench seating and even small side tables could help create a welcoming environment. These areas could also serve as informal touch down spaces for virtual team building events, such as Zoom coffee breaks, to provide ways for distributed teams to connect. And when able to step away from the floor for a rare longer break, or before or after a shift, easily accessible green roofs and healing gardens are especially important.

Another change since the pandemic has been that hospitals are decreasing the number of entrances and exits to facilities. Staff are usually diverted to one entrance where they can get their scrubs for the day and change their shoes. This area could also be an opportunity to create positive communication and gathering outside this door.

Enable peer support and mindfulness

A solid support system is crucial — especially at work. Employees who have a best friend at work are seven times as likely to be engaged in their job. When people have more friends in the workplace, they are more productive and less stressed. Calming spaces filled with comfortable furniture and soothing lights for healthcare workers to listen to one another and provide emotional support — such as affect labeling or putting feelings into words — as well as planning and problem solving, could help. These rooms could also provide spaces for staff to connect with a virtual therapist.

In addition, opportunities for caregivers to cultivate mindfulness and seek individual respite allow staff a way to recharge and find ways to cope with the stress of social isolation. Multi-sensory decompression rooms filled with gentle lights, sounds of nature  and images of a verdant forest, could promote rejuvenating, meditative retreats.

Strategies to Decrease Patient Isolation

As many hospitals reduce visitors, social isolation can be incredibly debilitating for patients too. While some hospitals allow one visitor, others maintain a no-visitor policy. Although a hospital with fewer visitors can be a quieter, more restful place, it can be lonely for patients, especially during their most vulnerable times. This is especially true because patients feel more comfortable and trusting of care when a family member is present, not to mention that it helps staff communicate with the family about the patient’s history and medications.

At times, these restrictions also require healthcare workers to take on the role of caregiver, family and friend to their patients. These challenges are also compounded with PPE requirements. In the era of the coronavirus crisis, communication between caregivers and patients is more nuanced and complex. Below are a few ideas to overcome isolation for patients.

Employ creative communication methods

In discussions with caregivers, patients and healthcare staff alike are retraining their communication methods. Many facial expressions and of course speech, are tied to the mouth, but facial coverings mask these cues and soften spoken words. Instead, eye and eyebrow movements may be even more essential to convey meaning.  One patient shared that they were not concerned about seeing their caregiver’s face because they “believe that people smile with their eyes.” This patient’s advice was to “focus on what you can see, not what you can’t.”

Increased focus on intentional or physical communication is key: staff can put photos of themselves on their PPE so patients can see what they look like behind their masks, while patients can also include photos of themselves and their families in their rooms. Celebratory rituals could also minimize patients’ isolation. When patients reach a certain milestone, or are discharged from the hospital, upbeat music and simple encouragement can be immensely uplifting.

Offer engaging technology

Technology can bring people closer together and provide positive distractions to help improve the patient experience. Wall-mounted screens in inpatient rooms that work in tandem with patient smartphones and iPads  could display medical information and history, but also provide video conferencing,entertainment options and relaxing music. These custom, built-in screens could also provide translation assistance to supplement current services. The post-traumatic stress for staff who have had to hold a phone up to a family member’s ear during their loved one’s last moments or being the vehicle for the patient to Facetime with family who are restricted from visiting is tremendous. We can do better.

Streamline entrances and exits

For hospitals that do allow visitors, streamlining entrances and exits with clear, direct signage is critical. For example, using recognizable shapes like circles and unusual colors like pink within the visual signage allows for visitors to navigate their way to, around and through the hospital.

Provide meaningful spiritual care

Spiritual care may offer a powerful means for patients to share their wishes, desires and fears. Within a hospital we tend to focus on the physical and medical, but not the spiritual. Patients who have no visitors want someone to listen to how their lives and their family’s lives have been impacted by their illness. Focusing on spiritual care is essential and can allow patients to reflect on life’s joyous and challenging moments.

A disconnect between caregivers and their work environment, and patients and their families, can create emotional exhaustion. Thoughtful and considered design does not need to come with a high price tag. Look for opportunities in planning and design where a small move can be the difference between functional and generous. From extra inches in stair widths and landings to ending corridors in glass instead of drywall to larger and more staff lounges, these design choices show the emotional well-being of the staff and patient is as important as clinical care and patient safety.

 

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 Chuck Choi.

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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 that helps reduce the coronavirus from spreading while supporting the ability for caregivers to deliver safe care. This includes sinks or hand-hygiene stations strategically located in each room, the introduction of a portable isolation room filtration system and the ability to have a nurses’ station located in the hallway. 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 courtesy Benjamin Benschneider/NBBJ.

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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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