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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Recalibrating Our Streets

What Types of Mobility Do We Want to Prioritize?

February 5, 2020

Planner / Architect, NBBJ

Editor’s Note: This post was originally published in ArchitectureBoston.

I’m sure I’m not the first person to return from a trip to Europe with a fresh perspective on urban life. But having recently traversed Copenhagen, Denmark, I’ve begun rethinking the role of Boston’s streets. The city’s fabulous organic street grid is similar to those in Europe that were built around walking, horse carriages, and the proverbial conversion of “cow paths” into modern streets. Boston’s crooked streets, like those of many medieval town centers, have served to make it one of the nation’s most walkable cities, but compared to Copenhagen, it remains remarkably focused on automobile traffic.

Copenhagen was not always a mecca for cyclists. After a long history leading up to and including the Second World War, when cycling was the dominant form of transportation, cycling in Denmark declined after increased prosperity saw an uptick in automobile usage. Danish urban planners — like other planners around the world — built urban expressways through poor neighborhoods and expanded lanes for cars to improve traffic flow. The result was a precipitous decline in cycling to less than 20 percent of travel in the late 1950s and 1960s.

The energy crisis of the early 1970s saw a reversal of this decline, and the introduction of Car Free Sundays in Copenhagen — to save fuel — was so popular that it sparked a movement to restore cycling as a serious mode of travel. Since the 1960s, Copenhagen has constructed about 250 miles of cycle paths separated from car lanes and sidewalks. Bicycles outnumber cars 7-to-1; a 2016 survey counted 267,700 daily bike trips compared with 252,600 for cars.

Despite modest progress, Boston is still many years behind Copenhagen in adapting its streets to uses other than for private vehicles: Washington Street and Summer Street as pedestrian promenades that largely exclude traffic; bus-lane experiments to improve flow during rush hours; bike lanes and Commonwealth Avenue’s newly completed off-road bikeway.

One illustration of Boston’s evolutionary thinking in roadway design can be found on Causeway Street. In 2007, Boston was beginning its Crossroads program, intended to reknit the city across the newly built Rose F. Fitzgerald Kennedy Greenway with pedestrian-friendly corridors. The staff at the Boston Redevelopment Authority (now called the Boston Planning & Development Agency) and a consultant team I was leading envisioned Causeway Street at North Station looking much like Dewey Square at South Station — where nearly 100,000 daily transit riders swarm the plaza every morning and evening.

Even though North Station has fewer riders than South Station, the station puts no less of a strain on Causeway Street during rush hours. We pictured Causeway Street as a gateway to welcome commuters entering and leaving the station, and improve the retail experience along the narrow sidewalks. But halfway through the design phase, the City received federal funding for the Connect Historic Boston Trail, which envisioned an off-street bike loop circling downtown and running the length of Causeway Street to connect the North End with Beacon Hill. The utilitarian result, built in 2014, is a two-way bike lane oddly running down the middle of the road without access to the stores or amenities along the street edges. Nor is there much in the way of aesthetic improvements or areas for landscape treatments.

At the time, the design community I spoke to was disappointed that the implementation of the Connect Historic Boston Trail had precluded the chance for Causeway Street to be a more beautiful gateway to the city. Today, The Hub on Causeway, a mixed-used development, is finally nearing completion, with the recent opening of a Star Market in September. Could the street yet again be up for rethinking as a gateway as well as a bike corridor? Ten years later, what would we build, and would it be different this time?

Causeway Street came to mind on my recent trip to Denmark. Much like Causeway, the generous bike lanes in Copenhagen, while providing some of the safest streets for cyclists, come at great cost to other amenities within the public realm. For example, few of the roads in this famously bike-friendly city have any street trees, and pedestrian sidewalk widths are narrow, some might say minimal, often forcing pedestrians to travel single-file past parked bicycles and outdoor seating. On-street parking is likewise absent on main thoroughfares. So, while Copenhagen is graced with fine and colorful architecture — which goes a long way to ameliorate the loss of trees — the dominant gray of asphalt, the relative space allocated to the various forms of mobility, and the lack of aesthetics speak to a rather single-minded optimization for ways to get around, with cyclists generally the largest users of street space.

Would Bostonians agree to such a bargain if it meant narrower sidewalks and the loss of landscaped areas throughout the city? Given the emerging green agenda — the desire to reduce heat islands and treat stormwater flows — a new range of priorities is emerging in Boston for the limited amounts of public rights of way. Another contender is the seemingly endless space needed for Uber and Lyft vehicles that perpetually clog travel lanes while they drop off or pick up passengers. Parcel deliveries from online shopping are also increasing: New York City, for example, recently reported that more than 1.5 million packages are delivered each day, clogging roadways with double-parked trucks.

Copenhagen has doubled down on the bike, and the results are spectacular in terms of reducing vehicle use within the city and therefore its carbon footprint — it is on target to be carbon neutral by 2025. Although Boston has made modest progress toward improving alternative forms of mobility, the facts are not encouraging: Between 2012 and 2017, the population in Boston grew by 7 percent, but household vehicle ownership in Boston rose by 15 percent. While some of this increase may be a result of off-street parking lots constructed as part of new housing developments, on-street parking remains a nearly sacred right in some of our most crowded and historic neighborhoods. In many of these neighborhoods without access to reliable transit — Dorchester, for example — it is painstakingly difficult to remove parking from streets in order to make room for bike lanes, bus lanes, or green spaces.

In Boston’s diverse neighborhoods, notions of a “complete street” may vary. Boston has complete-streets guidelines that attempt to balance the needs of drivers, cyclists, and pedestrians. But our narrow streets often demand prioritizing between an even wider set of goals. Advocates have competing priorities not only for street space but also for public funds that are needed to rebuild streets. Right now Boston and the Commonwealth have a host of challenges to address; how important is carbon reduction relative to an affordable-housing crisis or a failing transit system or sea-level rise?

Ultimately, recalibrating our streets is dependent on discussions far beyond a complete-streets manual. For example, a functioning transit system is essential to provide an adequate alternative to the private car. Despite the claims made by transit-network companies — Lyft, Uber — car ownership and traffic volumes continue to rise, at least in Boston. In the absence of an efficient rapid-transit backbone, can we downsize vehicle lanes without a serious backlash? Adequate transit can bring down car ownership rates and free up street space for other uses (and also lower the cost of housing). Only once an efficient transit system is in place can our streets be reconsidered for these other priorities: bikeways, sidewalk cafés, rain gardens, shade trees, or curb drop-off spaces for ride-share and delivery vehicles.

Sharing the road means first understanding what types of mobility we want to prioritize. Then we need to fund our infrastructure in order to achieve a Boston street that may look different from one in Copenhagen, but one that will reflect our values as Bostonians.

Banner image courtesy Febiyan/Unsplash.

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