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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How to Design a Hospital Triage Tent to Efficiently Screen for Coronavirus

Seven Factors Healthcare Facilities Can Keep in Mind When Designing Out-of-Hospital Testing Centers

March 19, 2020

Partner, 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 Tom Sieniewicz, George Takoudes and Tim Pranaitis.

 

As countries around the world respond to the coronavirus (COVID-19) pandemic, healthcare systems feel tremendous strain — from mask and ventilator shortages to a lack of patient beds. With the number of global cases on the rise, how can hospitals safely and efficiently test the “walking worried” — people who present with coronavirus symptoms or may have been exposed — before they step into the emergency department?

One strategy is to open a hospital triage tent, a temporary outdoor structure that is separate from a hospital’s emergency department. Here are a few factors to keep in mind when creating a similar space at your healthcare organization:

Employ empathy. Going to the hospital in any situation can be stressful, and especially so today. Creating a patient-provider experience that people can trust is crucial. This starts with understanding needs, from the “walking worried,” to nurses, doctors and security guards.

Select the right location. Identifying the right site is an important step. Is there an available parking lot nearby? Different than the drive-through testing model that was developed in South Korea, a hospital triage tent needs to be accessible to those on foot who may not have access to a car.

Consider the appropriate amount of space. Being able to test the highest number of people at one time while maintaining CDC protocols, such as social distancing of at least six feet, is critical. For example, a triage tent of 25 feet by 45 feet should hold no more than 15 people seated (but can accommodate up to 30 people total if accounting for the queue). Typically a space of that size can accommodate up to 50 people.

Select a tent with easy-to-clean materials. Providing a space that is as simple as possible to disinfect and sanitize is of utmost priority. On a recent triage tent in Boston, we coordinated with a tent company that has worked with the city’s fire department. The hospital is renting the triage tent on a weekly basis, which includes important essentials such as lighting, smoke detectors and HVAC. The walls are vinyl-wrapped tent fabric, which can be wiped down as needed and meet flammability requirements. The tent structure is aluminum and features concrete blocks to weigh it down and prevent uplift. All the furniture and fixtures were reused from the hospital.

Accommodate a safe and streamlined screening process. A triage tent must provide at minimum, space for four activities: a place for visitors to queue, a check-in zone, a waiting area and one or two private screening rooms.

Build in flexibility. In the rapidly evolving coronavirus situation, creating a space that can flex on a moment’s notice is key. The interior of the triage tent doesn’t contain interior walls, but instead uses screens that can easily move to different parts of the space for additional privacy.

Prioritize collaboration. Maintaining open lines of communication among all parties during a super-compressed timeframe can expedite the delivery process, and also make sure issues are resolved as quickly as possible. With the right approval frameworks in place, it’s possible to develop and assemble a triage tent in just a few days, which means employing rapid-fire decision-making and a design-permit-build process (that typically takes two years for a regular hospital project) that leaves no room for error. Having frequent conversations between ER staff, permitting authorities, project managers, lighting specialists as well as security and tent representatives lays the groundwork for a successful, speedy and safe project that supports providers, patients and visitors alike.

In these unprecedented times, we’re all learning new ways to be resilient, to adapt and to be resourceful. We hope the above framework helps provide insight into a new method to tackle this crisis.

 

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 Lucas Schimmak/Pexels.

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Want to Build a New Ambulatory Surgery Center?

Six Items to Consider Before You Start to Build Your Next ASC

January 27, 2020

Partner, NBBJ

Editor’s Note: This post was coauthored by Mackenzie Skene and Hao Duong. It was originally published in Becker’s ASC Review.

Ambulatory Surgery Centers (ASCs) promise to offer high-value services in a cost-effective environment. This is leading to tremendous growth, with the latest figures showing more than 50 percent of all surgeries in 2017 were performed in ASCs, compared to 32 percent in 2005. Organizations looking to capitalize on this trend by building new ASCs can do so, yielding expanded access, greater convenience and improved efficiency.

However, these benefits can only be achieved through careful analysis and preparation. Six ideas healthcare systems should consider:

  1. Improving access. 
    Bringing surgical services from the hospital campus to other communities may disconnect the ASC from ancillary support services. Consider what ancillary services are provided locally or served from the hospital. For example, centralizing sterile processing and pharmacy at the hospital may reduce costs, simplify staffing and maintain quality control standards. However, this may come at the cost of increased transportation demands, insufficient instrument and equipment availability, and an inability for staff to react to immediate needs. Recruiting and block timing can also be a challenge, as surgeon preference and access to outpatient clinical spaces for pre- and postoperative visits may be limited. This may result in patients bouncing between different facilities for everything from perioperative examinations to medications and durable medical equipment. Consider the thresholds that would trigger building redundant systems at the start of a project.
  2. Cost considerations. 
    Because ambulatory patients are typically healthier and undergo less complex surgeries than other populations, infrastructure requirements and room sizes are significantly less for an ASC. Even escaping the robust seismic and life-safety requirements of an I-2 hospital construction type can result in cost savings when compared to the cost of constructing a hospital surgery suite. But don’t expect all these savings if the ASC is expected to support more complex procedures. Building codes are slowly adapting to the trend where procedures historically performed in a hospital are moving to outpatient settings; and a certifying body can require the ASC to meet the standards of an inpatient surgery suite. Add in the high cost of construction and redundant staffing for local sterile processing and pharmacy, and the result can easily tip the cost scales. Consider whether accommodating more complex procedures erases the cost benefits of building an ASC.
  3. The 23:59 rule. 
    CMS states procedures requiring more than 24 hours (from intake through recovery) are not candidates for ASCs. As technology permits the execution of more complex cases in an ambulatory setting, organizations should consider providing additional provisions to patients who can go home within 24 hours but may want more time on site for education and physical transition. Some states already allow for extended recoveries, while others require that any such accommodation be distinct from the ASC and not offer direct medical care. ASCs considering this approach should talk to their local certifying body to work through the many details, ranging from clinical staffing to food services.
  4. Flexibility is key. 
    Designing a single-specialty ASC can maximize efficiency and reduce the need for extraneous storage, equipment variation and general overbuilding. However, this approach comes at the compromise of future flexibility, as elements not accommodated on day one may be cost-prohibitive to add later. Also, if an organization desires to lock in the future flexibility to perform many different procedure types by including them under their license or certificate of need, a certifying body may limit or revoke that license if the design only supports a subspecialty. Consider whether procedural flexibility is likely needed in the near future or just nice to have, and whether those components can be accommodated in other ways — like with a building that can be expanded.
  5. Building beyond essentials. 
    One appealing aspect of an ASC is the ability to build only what is essential. Operating room sizes can be reduced, perioperative spaces can be built for limited hours of service and infrastructure does not need to be as robust. With increased competition in the marketplace, though, an ASC should consider providing amenities for both the patient and caregiver. Adding a café can be good for families and staff, electrical outlets in furniture can keep people connected and comfortable beds to sleep on — not just a stretcher — can differentiate ASCs. Even a well-done integrated ceiling system in the OR can improve aesthetics and promote a cleaner environment. Consider what features might differentiate your ASC and attract more customers.
  6. Planning for emergencies. 
    Working with healthier patients does not mean procedures always go according to plan. As more complex cases are performed in the outpatient setting, relying on 911 for emergency situations may prove insufficient. A nurse call system may be necessary to augment communication among staff, and training a team to stabilize a patient while waiting for help may also be needed. Moreover, an ASC may find itself informally or formally designated as the default center for an individual or public health emergency due to proximity. Consider the difference between what is required versus what is likely to happen in the ASC, especially in rural areas.

The cost of constructing and operating an ASC depends on many factors. So, as an organization settles on the type and scope of a new ASC, a comprehensive analysis should be performed to confirm that this new project will provide the care patients deserve, and either increase revenue and lower costs, or alternatively move volumes from the main campus to another location.

Banner image courtesy Sean Airhart/NBBJ.

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