Article by Dr Jane Repin Carthey

Designing the healthcare environment to respond to the threats from COVID-19

Although the COVID-19 pandemic has been around for most of 2020, it is still so recent that there is relatively little published peer-reviewed literature offering practical solutions for longer-term health facility design responses. However, it is already becoming obvious that a much greater emphasis is being placed on infection prevention and control, and this will affect the design of future health facilities in Australia and other countries. Planners will have to respond to quite specific operational requirements that include testing and streaming of patients based on their COVID status in order to keep other patients and healthcare staff safe from infection. Drawing from the literature, five key issues are discussed in this post regarding health facility design responses to COVID-19 and future pandemics. They include:

1. Characteristics of the built environment affecting the spread of infections such as COVID-19.
2. Using Human Factors and Ergonomics (HFE) to develop operational procedures for achieving optimum human safety and performance – in particular triaging and assessing COVID-era patient presentations.
3. Operational issues to be considered in reopening and running outpatient and ambulatory facilities in the COVID-19 era, including the impact on the built environment
4. A summary of key findings from the Nuffield Trust Report into the NHS with recommendations regarding how healthcare buildings can assist with responding to infectious diseases and pandemics such as COVID-19.
5. Maintaining patient-friendly environments by accessing nature, with concurrent and appropriate infection control measures in place to manage threats from COVID-19 and other possible future pandemics.

Future posts will expand on, and add further findings to this list of resources. 

Characteristics of the built environment affecting the spread of infections such as COVID-19

Dietz et al. (2020) detail how to manage the built environment to reduce the spread of COVID-19. They outline the known factors that spread infections, and then some approaches that are useful for reducing the spread of viruses and other infectious agents within the built environment. The factors that may reduce the spread of infectious agents such as COVID-19 include the use of fresh versus recycled air in HVAC systems, correct use of HEPA filters, encouragement of handwashing and mask wearing, reduction in the occupancy of crowded spaces, and ensuring the correct range for humidity and other measures for air quality. They note the particular requirements of health facilities as follows:

“In planning for the future, architects, designers, building operators, and health care administrators should aspire for hospital designs that can accommodate periods of enhanced social distancing and minimize connectance and flow between common areas, while also affording flexibility for efficient use of space during normal operating conditions.” (p.10)

Using Human Factors and Ergonomics (HFE) to achieve optimum human safety and performance

Human Factors and Ergonomics (HFE) is defined as:

“…a discipline that examines the design of individual work system components and the interactions with each other, taking into account human capabilities and characteristics, with the goals of achieving optimum human safety and performance” (Gurses et al., 2020, p. 50).

HFE may be useful in developing workflows, routines and protocols aimed at ensuring the safety of clinicians and patients during a pandemic such as COVID-19. For example, for a patient presenting to an ambulatory care clinic, HFE may assist in developing processes for screening, registration and isolation protocols. Some solutions may be quite quick and practical e.g., appropriate signage while others may take longer and require the input of groups of experts.

Ideally, this work should be done prior to briefing or designing a health facility but some of it may take more time than allowed in the pre-briefing stage. This may be risky in terms of causing the need for re-design, re-documentation, or alterations during or following construction. For example, the use of PPE may require more space allocated for storage, doffing and donning, and this is difficult to provide retrospectively in order to maintain appropriate and safe work practices.

Operational issues to be considered in reopening and running outpatient and ambulatory facilities in the COVID-19 era, and the impact on the built environment

Valika and Billings (2020) outline operational issues that were implemented so that an otolaryngology outpatient clinic could be re-opened in Illinois, USA. During the initial period of high numbers of COVID infections, many surgical cases were postponed, and clinics were conducted using a mixture of limited in-person visits and telemedicine. This is similar to the situation in many hospitals in Australia. Once the pandemic curve began to flatten, the criteria for elective healthcare visits were loosened and the need for a new “normal” that kept patients and staff safe was recognised. Strategies adopted included:

• Creating team-based models focusing on sub-speciality lines of care with less crossover between teams including use of clinic rooms and treatment areas;
• Contacting existing patients regarding their interest on keeping or rescheduling outpatient visits – enabling the teams to focus on scheduling new patient visits;
• Maintaining social distancing;
• Incorporating telemedicine wherever possible;
• Establishing protocols for PPE use during procedures;
• Pre-screening patients before their visits;
• Revising the practice of double-booking appointments to single appointments and greater use of telemedicine – in order to enable more compliance with social distancing within waiting rooms.

Some or all of these mainly operational strategies have been trialled or used by most healthcare providers. The implications for the provision of physical space and the design of ambulatory or outpatients clinics will include the need to adapt in the future to support these refined care models.

A summary of key findings from the Nuffield Trust Report into the NHS in early 2020

The Nuffield Trust Report (Edwards, 2020) looked in more detail at how healthcare design approaches over the last few decades are impacting on the ability of hospitals to respond to the demands of the current pandemic. Some of the significant or noteworthy points it considers include:

• Design Issues such as hospital accommodation requirements and layout:
• • Designing for “loose fit” and generous circulation space. This is contrasted with the elimination of extra space to reduce cost which has been occurring over the last few decades. This is similar to the Australian experience driven by the use of design guidelines and efficiency measures for circulation, travel, etc;
  • Providing a majority of single patient bedrooms – a direction that Australian hospitals are embracing, although not yet fully achieved;
  • Where it is not possible to have all single rooms, which may be the case in older or rural hospitals, cohorting patients in shared accommodation in terms of whether they are high or low risk in terms of COVID or other infections could be pursued;
  • Making corridors wider to keep flows separate and to allow for distancing especially when transferring patients from one part of a hospital to another. In Australia, it may be necessary to test whether the 2.4m corridors required by the design guidelines serve this purpose;
  • Emphasising the need for Personal Protective Equipment (PPE) including more space for donning and doffing PPE, and more handwash basins generally in-patient care areas. This is difficult and expensive to provide retrospectively without compromising other functions such as storage or circulation paths;
  • In Emergency Departments ensuring adequately sized waiting rooms to allow for social distancing plus more isolation rooms and single rooms depending on how patient flows are managed within the department;
  • Providing places for people to buy and consume food safely while social distancing.
• Patient management:
• • Separating operational and clinical flows for infectious patients in all departments;
  • Noting that parallel or duplicated assessment units may be required, and this will require more staff, although telehealth may be used in outpatient areas for this purpose;
  • Segregating infectious patients within Intensive Care Units (ICU) is critical, and this is already happening.
• Demand issues and capital investment:
• • To address increased demand for ICU beds, other spaces may need to converted to ICU functions e.g., operating theatres, recovery spaces, endoscopy units although clearly this cannot be a long-term solution when normal healthcare services resume. Flexibility and adaptability in design and fit out are required to be able to repeat this, if necessary, in the future;
  • Additional capital investment may be required to support the separation of flows for infectious and non-infectious patients through a hospital e.g., extra Medical Imaging capacity may be necessary, more or larger waiting areas, more and bigger lifts to cope with social distancing, and to promote direct access to facilities and services in multi-storey buildings without mixing patient groups or infectious with non-infectious patients;
  • It may be necessary to run hospitals at lower occupancy rates e.g., 75-80% as opposed to 90% or greater which is often the target at present. This may require more beds than presently provided and may argue against bed reductions in Australia and other countries;
  • Reduced volumes of elective care in the public sector may see an even greater use of the private sector for this in the future.
• Diagnostics, tests and screening:
• • The need for Point of Care pathology testing will be increased for high risk services such as ENT, Ophthalmology, Oral Surgery and Endoscopies;
  • Greater need overall for diagnostic services;
  • Current reductions in presentations for routine tests and screening (such as BreastScreen, Bowel Screen, etc) will eventually create a backlog that will need to be managed and spread out so as not overwhelm staff or other resources.
• Technology:
• • Greater shifts to use of telehealth and telephone consultations may reduce need for traditional clinic rooms but increase the need for greater IT support and spaces to make these calls or hold that type of meeting.
  • Presentations, screening and streaming:
  • Considering how to manage people presenting at EDs perhaps by insisting on the use of GP or other clinical referrals – as occurs in Denmark, Norway and the Netherlands;
  • Define some hospitals as “Covid-free” as happened to some extent in China – this may not be possible in rural or regional areas where there may be only one or, at most, two hospitals;
  • “Streaming” within hospitals of patients and staff e.g., designating “infection-free” areas, separate buildings, defining different routes through the hospital, involving the private sector in this streaming approach;
  • Separating emergency and elective activity to different sites to reduce risks of cross-contamination;
  • Centralising services even further e.g., paediatrics to manage risks to those patient groups.
• Other Health Delivery Issues:
• • There will be impacts on primary care, which we are already seeing in Australia with reduced demand due to people postponing non-critical care including check-ups, etc. Sooner or later pent-up demand will need to be addressed.
  • There will also be effects on rehabilitation services especially in the community and social care generally. Many of these services are used by high risk patients e.g., older people or those with co-morbidities. Consider the impact of this on care delivery and the use of physical facilities especially where these are centralised or part of a larger hospital campus.
  • Post-Covid services will be needed to assist with multi-system rehabilitation needs such as pulmonary follow-up for patients with lung fibrosis or those needing psychological interventions following a stay in ICU.

This is a good and detailed summary of factors to be considered in looking to the future design of healthcare facilities for the Australian and other communities. These will be added to in future posts on this topic.

Maintaining patient-friendly environments by accessing nature

Finally, Sachs (2020) discusses the importance of maintaining access to nature while dealing with COVID-19, and continuing to provide a patient-friendly environment. Given the need to wear PPE while dealing with patients, reminding ourselves of the human element is also important at this time. Sachs questions whether healthcare facilities are now using outdoor space differently than before. For example, she discovered in one facility that staff were using gardens more than ever as respite from the stress and intensity of their daily work. Although patients and visitors were also discouraged from congregating in some outdoor spaces in some facilities, in others there was increased use of outdoor areas – again for stress relief and a break from the intensity of the COVID-19 treatment environments.

She notes that: “…in addition to feeling safer outdoors, people seem to be enjoying the outdoors more. They are discovering the beauty and joy that nature has to offer” (p.3). She finishes her editorial by hoping that this apparently newfound appreciation for gardens and the outdoors continues to be the case post-COVID in the design of healthcare facilities. This is a sentiment shared by many designers and healthcare workers.

References

Dietz, L., Horve, P. F., Coil, D. A., Fretz, M., Eisen, J. A., & Van Den Wymelenberg, K. (2020). 2019 Novel Coronavirus (COVID-19) Pandemic: Built Environment Considerations To Reduce Transmission. mSystems, 5(2), e00245-00220. doi:10.1128/mSystems.00245-20

Edwards, N. (2020). Here to stay? How the NHS will have to learn to live with coronavirus. Retrieved from https://www.nuffieldtrust.org.uk/resource/here-to-stay-how-the-nhs-will-have-to-learn-to-live-with-coronavirus

Gurses, A. P., Tschudy, M. M., McGrath-Morrow, S., Husain, A., Solomon, B. S., Gerohristodoulos, K. A., & Kim, J. M. (2020). Overcoming COVID-19: What can human factors and ergonomics offer? Journal of Patient Safety and Risk Management, 25(2), 49-54. doi:10.1177/2516043520917764

Sachs, N. A. (2020). Access to Nature Has Always Been Important; With COVID-19, It Is Essential. HERD: Health Environments Research & Design Journal, 1937586720949792. doi:10.1177/1937586720949792

Valika, T. S., & Billings, K. R. (2020). Back to the Future: Principles on Resuming Outpatient Services in the COVID-19 Era. Otolaryngology–Head and Neck Surgery, 0194599820933597. doi:10.1177/0194599820933597