Many Rural Hospitals Are Not Prepared For COVID-19 Surge. Here’s How They Can Be.

Five Design and Planning Strategies Will Be Critical to Adapting to the Pandemic

April 30, 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 initially appeared on Forbes. It was co-authored by Teri Oelrich and Bryan Langlands.


So far the coronavirus pandemic has been concentrated mainly in New York, Detroit and other major cities. But there is a problem brewing that has received little attention: over two-thirds of rural counties have now reported COVID-19 cases. The pandemic presents a formidable challenge for rural hospitals, which have faced 120 hospital closures over the past decade and frequently struggle to recruit staff and balance the books.

The effects of the pandemic on rural hospitals don’t make the headlines the same way major cities do, partially because the problem is spread out across places many have never heard of. For example, Idaho’s Blaine County has one of the highest infection rates in the U.S. With only 25 hospital beds, Blaine starkly illustrates how the virus can rapidly overrun the healthcare infrastructure of rural communities.

There are critical steps rural hospitals can take now to adapt to the pandemic. Here are five design and planning strategies that will be critical to success.

Develop regional care strategies

Rural communities are usually served by small hospitals that frequently lack the capacity and resources necessary to deal with a spike in COVID-19 cases. One method of mitigating this shortcoming is to develop a regional care strategy with other rural facilities in the region, in which patient care is coordinated to enhance capacity and minimize infection risk.

Areas with multiple hospitals within a roughly 150-mile radius should begin designating one facility as a COVID-19 hospital and care for non-COVID-19 patients at other facilities. The non-COVID hospitals could then potentially perform elective treatment and alleviate some of the financial burden caused by the crisis. Tools like this COVID-19 Inpatient Bed Demand Calculator can help in determining local and regional capacity needs and where coordination may be most beneficial.

Alternative care sites, such as converted dorms, motels or hotels, can also be used to care for non-COVID-19 patients or to monitor less severe COVID-19 cases. Missoula, Montana, for instance, is planning to purchase a motel to use as a safe shelter for those isolating and self-quarantining during the pandemic. Similar buildings can also be repurposed to house caregivers who treat coronavirus patients, or to house out of town doctors, nurses and staff temporarily assisting beleaguered hospitals.

Rural hospitals can also partner with larger urban hospital systems to support care needs. Telemedicine can help provide input from specialists that don’t typically live in rural areas. It could also help rural hospitals receive temporary ventilators, PPE distribution and clinical staff.

Apply for federal aid

While the CARES Act includes a number of provisions to assist rural hospitals— including small business loans, $100 billion in new funding, and Medicare payment improvements— providers can also apply for FEMA Public Assistance (PA) funding. Certain emergency protective measures taken by hospitals in response to COVID-19 are eligible for reimbursement at 75% federal cost-share under the PA program, which is using a new streamlined application process. Applying for federal funding is no small task and requires significant investment in time and follow up documentation. Often hospitals engage consultants who have been successful with previous federal applications to assist them with this process. There is good news though: the cost of consultants to handle applications is covered by FEMA.

Prioritize clear signage and wayfinding

It is critical that COVID-19 patients are able to seek care without inadvertently infecting the general hospital population. This is especially true for rural hospitals, where care for more vulnerable long-term care patients is frequently integrated within the facility. Navigating in and around a hospital can be confusing and stressful, which makes signage and wayfinding vitally important for getting COVID-19 patients where they need to go while minimizing the risk of infecting others.

It is important to have a comprehensive wayfinding system for COVID-19 patients that is succinct, unique and recognizable. For example, using an unusual color like pink to direct patients to the right place helps the signage stand out, as does simple language like, “Follow the pink circle if you have COVID-19 symptoms such as dry cough, fever, and shortness of breath.” This unified wayfinding theme should be employed at every step of the patient’s journey, from the hospital website to signage as patients approach and enter the hospital. COVID-19 patients arriving in personal vehicles could, for example, be directed by signage to a separate parking lot to wait to be tested before entering the hospital.

Screen patients in triage tents

One method of minimizing contact between potentially infectious and non-infectious patients is to set up a triage tent for COVID-19 screening. This is a temporary outdoor structure, frequently set up in a parking lot, which is separate from the emergency department and enables patients to be triaged before they enter the facility. A triage tent must accommodate space for at least four activities—a place for visitors to queue, a check-in area, a waiting area, and private screening rooms. Because the interior of the tent has no walls, screens can be used to create separation and privacy, in addition to flexibility.

Tents need to maintain CDC protocols, such as social distancing of at least six feet, while being able to test the highest number of people at one time. For example, a triage tent of 25 feet by 45 feet can hold no more than 15 people seated. Ensuring the space is as simple as possible to clean and sanitize is also critically important. Frequently vinyl-wrapped tents are used along with furniture and fixtures from the hospital. Some hospitals have even rented tents, complete with lighting, smoke detectors and HVAC, from fire departments.

Make common areas safer

Ensuring safety is an ongoing challenge for hospitals. It is of particular concern in common areas like building entrances, waiting rooms and lounges, where patients and visitors congregate and transmission risks may be more acute. There are several design strategies that can help mitigate these risks while still reassuring and comforting patients and visitors.

Material and furniture selection— including the use of antimicrobial surfaces like copper and easy to clean furniture pieces with seamless detailing and solid surfaces— can help minimize the risk of coronavirus surface transmission. Similarly, touchless surfaces like automatic doors and hand sanitizer dispensers can reduce infection risk. Seating arrangements can also be moved or otherwise modified to create sufficient space between patients to support social distancing. It is also advised to divide patients into infectious and non-infectious groups, supported by adequate signage and physical separation.

As the pandemic expands into rural communities, their hospitals are tasked with the difficult job of safeguarding the health of communities that are typically older, less affluent and less healthy than urban populations. While constrained by capacity and resource challenges, rural hospitals also have a history of adaptability and flexibility that may enable them to deal more nimbly with the rapidly evolving pandemic landscape. Design and planning strategies such as those outlined above can play a major role in supporting them in this critical work they are doing for the communities they live in and support.


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

Banner image courtesy Luke Hayes.

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We Need More ICU Beds. Rethinking America’s Individualized Healthcare Mentality Can Help Get Them

With Prefabricated, Open Ward-Style Treatment Spaces We Can Rapidly Scale the Number of Beds

April 16, 2020

Healthcare 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 initially appeared on Forbes. It was co-authored by Ryan Hullinger and Bryan Langlands.


For years, America’s healthcare industry has operated from an abundance mentality, with hospitals assuming access to virtually unlimited resources. But we are just a month into the United States’ COVID-19 crisis and hospitals across every corner of America are finding themselves in the midst of a threefold lack of resources — of appropriate space, of healthcare workers needed to address the crisis, and the necessary level of personal protective equipment (PPE) to keep frontline staff and patients safe.

Though the outlook feels bleak, the current pandemic is a chance for the healthcare industry to reevaluate deeply held beliefs around patient care and comfort. Most notably, the primacy of private patient rooms and specialized nursing units as across the board solutions. Both healthcare professionals and the general public need to forego the ideal patient experience as a primary focus for the American healthcare system. Instead, it is imperative that they move to an emphasis on patient safety and survival.

It sounds like a paradox in the midst of an infectious outbreak, but augmenting single-patient rooms with prefabricated, open ward-style treatment spaces ensures we can rapidly scale the number of beds in our country. While some hospitals at the forefront of the crisis are beginning to adopt versions of this model, the scale of this crisis requires solutions that are more integrated, faster to build, and easier to deploy across geographies.

One solution is pre-fabricated ICU units: a process that builds the components offsite to allow easy assembly onsite, saving time and money. Developed recently for use in future hospitals on the East Coast, these ICU units can be integrated into unorthodox and temporary treatment areas inside hospitals like cafeterias, clinics, conference centers, and parking structures. It can also be used beyond the hospital in civic spaces like arenas, schools and community centers.

Hospitals can arrange these temporary units in modules of 12 to 18 beds that come pre-fitted with essential ICU functions like regulated gasses, air and data. Grouping beds into larger modules maximizes caregiver sight-lines and allows nurses to oversee a greater number of infected patients in a smaller area, minimizing the staff required to care for patients. These groupings also have the potential to extend the average length of use for some PPE by reducing the need for staff to don and doff protective equipment repeatedly, as they do in typical nursing units each time they enter and exit private patient rooms.

Specialized medical equipment manufacturers have been developing and producing key elements found within the ‘plug and play’ solution for years as a part of the nation’s hospital building boom. By marrying the two together — the “plug and play” ICU unit and redirecting existing units intended for construction projects — we may be able to help quickly offset some of the stress on today’s hospital systems.

Now we must shift that energy to respond to the crisis today. Doing so means that, at least temporarily, we must focus less on the individualized and specialized care model that has been a hallmark of American healthcare, and more on the infrastructure and solutions that will save the most lives.


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

Banner image courtesy Frank Ooms/NBBJ.

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How to Rethink Wayfinding to Increase Infection Control and Decrease Patient Stress

Three Ways to Guide Hospital Visitors Seeking Coronavirus Care

April 13, 2020


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 Eric LeVine, Janet Dugan and Alexandra Alfaro.


As hospitals across the world flex to meet a surge of coronavirus cases, they are rapidly adapting their facilities to accommodate testing, infection control and inpatient care. However, navigating to, around, and in a hospital — particularly under these quickly-evolving circumstances — can be stressful and challenging.

Studies show high levels of the stress hormone, cortisol, can decrease memory and critical thinking skills. Even during normal circumstances, 30 percent of hospital visitors find it difficult to get to the right place because they get lost. Today, some people with coronavirus symptoms, many severely ill or under duress, enter the hospital without alerting staff before they are triaged, potentially exposing others unnecessarily to the illness and requiring staff to then isolate them, triage them and disinfect any spaces that may be contaminated.

1. Deploy a comprehensive wayfinding system for COVID-19.

Given this urgency, it’s critical to employ a consistent wayfinding system for COVID-19 (PDF) to help direct patients to the right place. The good news is hospitals can quickly improve the patient experience now with a comprehensive set of environmental graphics that address a visitor’s spectrum of interactions — from pre-arrival to discharge — with unified elements such as simple shapes, unique colors and a list of COVID-19 symptoms. Here are a few items to consider when creating signage for the crisis.

Graphic design and content recommendations

Keep signage simple to decrease anxiety. Graphic design treatments such as using the color pink, which is unique from typical hospital signage colors, can help important messages pop. Recognizable shapes like circles or squares are both noticeable and simple. Much like retail stores, such as Ikea with its clear, visible and instantly recognizable signage, hospital wayfinding that relies on repetition, standardization and familiar shapes can help people quickly orient themselves and lead them through a space in an intuitive way.

Reduce text to only the essentials so directions are easy to digest. Outline primary symptoms of the coronavirus to help visitors differentiate between other illnesses like the flu. For example: “Follow the pink circles if you have COVID-19 symptoms such as a dry cough, fever and shortness of breath.” Signs for non-COVID medical conditions could include language such as: “Follow the green square for non-viral treatment or care.”

Consistent visuals and content should be carried through all steps of a hospital visitor’s journey, from pre-visit information online to outdoor signage at arrival, to indoor navigation once visitors are through the hospital entrance. It is key for hospitals to utilize a wayfinding system that is easy for patients and healthcare staff to understand and follows a unified theme.

Website notices

To better welcome and inform visitors before they get to the hospital, it’s crucial to incorporate coronavirus-related wayfinding graphics into pre-visit messages. These should use the same colors and shapes as on hospital signage for COVID-19, so there is a consistent look and feel when a visitor arrives on site.

Pre-visit information can include online notices featured on the top of a hospital’s homepage, on social media, or a dedicated landing page that can be regularly updated. For example, using a URL like “” will rank higher in search results when patients query “Hospital Name Coronavirus.”

In addition, be sure to address: Where should people go to get tested? Are directions to the campus straightforward and concise? Provide these details succinctly up front to clarify any confusion. Given the highly-contagious nature of the coronavirus, this can help ensure visitors who may present with COVID-19 understand any special protocols ahead of arriving at the hospital to help keep the public and caregivers safe.

2. Prioritize signage.

It’s important to consider the placement of signage to help guide visitors before and when they step foot into the hospital. Signage allows patients to self-triage prior to entering the hospital. It streamlines the process for emergency departments, reduces patient stress upon arrival and increases the ability to identify infectious patients, making arrival safer for all. It also provides guidance for patients that may not have seen pre-visit information online or forgot the instructions.

Moreover, wayfinding should accommodate various modes of arrival. Consider the hospital setting and what type of transportation people use to get there. For example, suburban hospitals tend to have more visitors arriving via car versus urban hospitals, where many people travel by foot, public transportation and rideshare. Accommodate each mode accordingly. People in personal vehicles with coronavirus symptoms can be directed to designated parking lots to wait, queue and even be tested from their car before entering the hospital. Meanwhile, visitors arriving by foot can be guided to special coronavirus sheltered triage areas outside of the emergency department.

Signage locations can include highways, vehicular entrances to the hospital campus, outside hospital doors and more.

Adjacent highway signage

For drivers, temporary highway notices about COVID-19, mounted near existing hospital signage, can help visitors capably navigate with confidence.

Site threshold informational signage

Signs placed before entering the hospital campus can separate visitors with coronavirus symptoms from non-COVID-19 medical conditions.

Onsite directional signage

Signs mounted to existing infrastructure outside of the hospital, such as light poles, can provide parking or walking directions for visitors. These signs could also include a list of COVID-19 symptoms.

Onsite A-frame signage

Additional graphics, movable by staff, can provide further instructions to visitors, like which entrance to use or any safety precautions to take, before stepping into the hospital.

Interior wayfinding signage

Temporary wall signage allow staff to direct the flow of patients and identify critical supply locations as needed. Floor decals spaced six or more feet apart can also ensure proper social distancing and direct patients to exam or isolation rooms. Slim interior stanchions can also be helpful, but should be properly secured so they remain in place.

3. Address accessibility.

Just as hospitals are designed to accommodate accessibility, wayfinding systems should too. Special graphic design treatments like dark outlines and clearly-recognizable shapes can help visitors with color blindness navigate a facility. Meanwhile, using iconography — visual symbols and images — can improve comprehension for non-English speakers.

By employing a wayfinding system that is simple, bold, and inclusive — produced with minimal logistics and a low implementation cost — hospitals can create a calming, safer and streamlined experience for visitors, patients and healthcare staff during the coronavirus pandemic, and also be prepared for future events that require specialized navigation.

Click here to download the PDF: COVID-19 Response – Patient Self-Sorting Signage System

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

Banner image courtesy Sean Airhart/NBBJ.

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