Hospital Design for the Pandemic Era
While mortality due to the COVID-19 virus seems to be trending downward, the number of new infections continues at a high level. As of this writing, there are over 146,000 new infections and over 2000 deaths daily in the US. In the aggregate, 77,837,693 cases have been reported since January of 2020 with over 920,097 deaths. [i] Hospital systems that have managed to distribute care through the past 18 months are once again in danger of being overwhelmed. Front-line health care workers have been challenged continuously for the better part of two years, and now they are asked to risk even greater exposure as the number of patients in Intensive Care Units (ICU) and Emergency Rooms (ER) swell.
As waves of infections caused by the SARS-CoV-2 virus wash through the general population, it is easy to imagine that the strategy of locking down populations and closing businesses that require close interaction between individuals may not be the best strategy. Or, have the State-mandated restrictions not been applied aggressively enough? Perhaps. But we believe it more likely that some decisions made early in the fight against this disease have shaped our current approach. It is not too late to correct these early choices. But before we discuss the potential solutions, we should look all the way back to the Spring of 2020.
What do we know?
The following statements are condensed from the articles linked in the bullet points.
1. Throughout history and especially in a global economy driven at jet-speed, the spread of infectious diseases as cyclical pandemics seems inevitable.
2. The danger that such pandemics can quickly overcome existing healthcare delivery systems is real.[ii]
3. Concentrating patients suffering from viral infections in pandemic conditions in existing hospitals renders those facilities virtually unusable for any other purpose. [iii]
It is difficult, if not impossible, to predict where viral diseases will be most prevalent.
What have we learned?
1. The reaction of government at all levels is to go BIG early and scale back services as meaningful data is collected and the picture of the epidemic becomes clearer. This strategic decision to plan for the “worst case” healthcare challenge often leads to a misallocation of resources. [iv]
2. Accurate data collection and identification of vulnerable populations is critical in determining the strategy for combatting the effects of an epidemic. [v]
3. When the traditional hospitals are used for treatment of virus sufferers and ‘elective’ procedures are postponed, the business of healthcare delivery and hospitals suffer as well. [vi]
4. Government mandated ‘shelter-in-place’ and ‘self-quarantine’ helps alleviate the pressure on intensive care services, but the isolation of otherwise healthy persons has devastating economic and mental health costs.[vii]
If we were to synthesize these observations, it is difficult to conclude anything but the obvious: the strategies that we are employing are not working for the hospital health care system. We should be pursuing the goals and objectives that accept the realities of the demographics of the COVID-19 pandemic. We should create healthcare systems that protect the most vulnerable in our society. Finally, we should separate and isolate the existing general health care system from the pandemic-specific challenges.
Because there is a facilities-based solution to the challenge of creating a pandemic-scale healthcare delivery system, the last two goals are the focus of our thoughts.
The challenges of a facilities-based solution would be profound. However, we can define the terms under which we could comfortably declare success.
The ideal Pandemic Hospital would be designed to emulate a large, urban hospital ICU in function, but be small enough to take advantage of an ideal patient/caregiver ratio. It would have all the technology of a modern hospital, but none of the space-eating support facilities, such as kitchens and laundries. Through the careful selection of materials and systems, it would require the minimum effort to maintain a clean environment for both caregivers, staff, and patients. It would concentrate itself first and foremost to patient care.
In addition to these core requirements for success, we would add that the capital cost for the Pandemic Hospital must be less per square foot than any comparable hospital. The design of such a facility must be easily scalable and capable of reproduction using pre-engineered principals. Inasmuch as the Pandemic Hospitals cannot be pre-positioned to meet unpredictable demands, the hospital must be able to be deployed to a wide range of locations and climates without losing operational efficiency. Finally, the Pandemic Hospital must be a part of the national healthcare system and capable of sharing patient health information into the national Center for Disease Control and Prevention (CDC) database in real time.
The Pandemic Hospital Solution
Meeting the criteria required above is a monumental challenge, but the elements of the solution are clear.
• The structure and the building envelope should be pre-engineered and easily repeatable.
• Building systems should be pre-fabricated and replaceable supplies pre-manufactured.
• The ideal ratio of patients to caregivers should be pre-determined and the design of the facility based on those ideal numbers.
• The individual Pandemic Hospital should be designed to be scalable vertically or horizontally.
• The spatial organization should be layered and air control systems cascaded.
• Connections to the CDC national database should be created either by satellite or fiber-optic connection.
• The Pandemic Hospital must be able to be dismantled and relocated to alternate sites or stored for later use.
To accomplish this, we propose the design of a new class of small, ICU equipped hospital with the following elements.
• Exterior Envelope: As previously suggested, the exterior envelope should be based on repetitive shapes supported by a pre-engineered metal frame. The foundations may be permanent. However, thought should be given to portable alternatives such as screw footings or similarly transportable systems. To the extent possible, the structure should be raised above the native terrain to allow electrical service and plumbing to serve the spaces from below the structural floor deck. This will limit the amount of grading and time required to make the site operational. Roof systems should be modular in design and have sufficient insulation values to meet the most stringent State requirements. The use of full-height windows is to be encouraged, but only to the extent that exposing the interior to direct sunlight is carefully modulated.
• Building services such as electrical and data rooms, mechanical equipment rooms, maintenance, and non-medical storage should be contiguous to the operation of the building but remote from public contact.
• Interior Organization: We have seen in our daily lives that separating the infected from the otherwise healthy population has a positive benefit and protecting healthcare workers from prolonged exposure is a vital strategy in combatting the effects of the virus. The Pandemic Hospital should be designed in the same manner. The core processes of the hospital should be separated from the patients and the patients separated from casual contact with the outside population.
• Public Areas – Waiting areas, administrative offices, public restrooms, counseling services, and chapel areas should be separated from the patient and caregiver areas. The public entrance should be separate from the building entry designated to the healthcare professionals. To the extent possible, the opportunities for physical contact between the healthcare staff and the public should be controlled and minimized. Similarly, the opportunities for contact between visitors and the patients should be tightly controlled.
As in any ICU, there should be a constant visual connection between the caregivers and the patients, as well as the ability to easily move the patient into the core for emergency procedures. To the extent possible, the distance required to provide health services to the patients should be equal.
Furthermore, the core services that the Pandemic Hospital will offer will supplement those of any ‘big city’ ICU. The core services will be operated by the healthcare staff and be divided into four (4) basic groups:
• Communications – These services will include patient monitoring and direct communications with the databases of the CDC and National Institute of Health (NIH), as well as State Health Departments. In addition, dispensing of medications will be controlled and monitored from this area.
• Chemistry Laboratory – Basic serology and blood analyzer, microscopes and centrifuges, culture incubator, diagnostic equipment, serum bath, and reagent storage will take place in this service area.
• Nutrition – Preparation and dispensing of pre-packaged meals of dietary and nutritional consistency. In order to maximize the use of available space, it can be assumed that there will be no dishwashing function and that all meals, including flatware and trays, will be disposable.
• Sterilization – The services provided from this area will include washing and sterilization of all non-disposable instruments and equipment. In addition, the storage and inventory of all gowns, bed linens, and other protective coverings will occur here. It is anticipated that the inventory of these products will be of disposable, non-woven, fabrics.
Additional core services may be desirable. These may include Procedure Room(s) and/or Operating Rooms.
• Patient rooms will be observable to the personnel providing the core services. It is essential that each room be single occupancy and be equipped with the full range of med gases, vacuum, and air, as well as individual bathroom and shower facilities.
• Facility Operations – There is an ideal relationship between the number of patients and the number of caregivers. The quality of care in a typical, modern hospital ICU degrades when the patient to caregiver ratio is higher than 2.5 and decreases dramatically when the ratio exceeds 14 to 1. For this reason, it is recommended that the number of ICU beds be not less than 20 and not more than 25, with an average per shift staffing load of between 8 and 10 caregivers.
What would this Pandemic Hospital look like? Are you looking to implement a Pandemic Healthcare solution like this? Contact Meier Architecture • Engineering at https://meierinc.com/contact/ or give us a call at (509) 735-1589 to get started.