June 2020, Volume XXXIV, Number 3
COVID-19’s influence on facility design
Considering patient and provider safety
here is no denying that the world is a different place than it was a few short months ago. A seemingly healthy economy has been leveled to its knees and daily patterns and behaviors have changed dramatically. There is not a single industry that has been unaffected by the COVID-19 pandemic—some positively, most negatively. As we emerge from the pandemic, many positive changes will follow. Some of these will involve rethinking health care facility design. These changes will vary based on specialties and where the care is provided.
What will the new health care environment look like? Changes in health care facility design will likely follow a three-stage process. There will undoubtedly be short, mid-term, and long-term modifications required as the health care industry moves to a new normal. One thing is certain: planning principles associated with the layout and design of medical buildings and clinical environments will change in a variety of ways.
Short-term solutions—emotionally driven
Social distancing, stringent hygiene practices, and isolation will be part of the new normal in clinics and hospitals. The importance and emphasis placed on these behaviors will require a needs assessment of each facility to identify potential gaps and vulnerabilities. Walking through existing spaces and viewing each area through the eyes of a patient or staff member will present the need for one or many of the following solutions:
Create spatial barriers between the patient and staff at the check-in desk.
Expand use of electronic check-in and self-check-in kiosks.
Reconfigure waiting areas to incorporate spacing and back-to-back seating arrangements versus those facing one another.
Implement cleaning stations in the public areas.
Plan for one-way traffic flow of patients into and out of the exam areas.
Adjust procedure schedules to allow time for room disinfecting between patients. This may require that clinic hours be extended with split shifts of staff to accommodate more visits per day.
Reconfigure existing underutilized exam space to accommodate telehealth capabilities.
When executed properly, these examples of proactive planning offer a comforting, safe, and welcoming environment that instills confidence in patients and staff alike.
Medical buildings and clinical environments will change in a variety of ways.
Mid-term solutions—research influenced
As more research is gathered surrounding this pandemic, we will begin to see more complex solutions put in place that will provide comfort and confidence to health care administrators as they invest in modifying their facilities. These solutions may include:
Space plan modifications that create larger, more flexible waiting areas to meet distancing requirements while compressing other spaces to maintain the same footprint.
Medical Office Buildings may seek to develop accessible exterior locations to provide a canopy for drive-up testing.
Enclosing open patient treatment spaces such as infusion bays for control of airborne particulates.
An upgrade of materials and finishes may be required throughout to incorporate bleach-cleanable fabrics and surfaces. A recent Johns Hopkins report states: “So far, evidence suggests that the virus does not survive as well on a soft surface (such as fabric) as it does on frequently touched hard surfaces like elevator buttons and door handles.”
Ventilation, purification, and humidification play a key role in mitigating the spread of infections. Additional research will likely change requirements in this area and an assessment by a qualified HVAC partner will become necessary. Facilities will look to make modifications to the existing HVAC systems to improve air flow and filtration.
Research will continue to drive modifications that health care facilities will seek in the next 12 to 18 months. Rest assured, patients beginning to make their way back to their normal well-patient visit schedule, and even those who seek specialty care, will approach that care and ultimately make a provider selection based on emotional and intellectual information gained as a result of the COVID-19 experience.
Long-term solutions—yet to be defined
As research and models continue to be developed and assessed, changes are on the horizon. The health care industry will look to advancements in technology that may change the level of interaction between the patients and care providers at different times during a patient visit.
We have noticed a change in the pre-registration process, with fillable forms being sent via email and submitted prior to a visit to reduce wait times and interaction. This will most likely become commonplace as facilities seek to reduce the number of patients in the facility at one time. The ability to check in for an appointment with a smart phone or at a self-check-in kiosk will also reduce interactions as the six-foot social distancing does not offer a great deal of privacy during the check-in process.
We anticipate future building code modifications may impact all building types and functions but will directly impact health care environments in response to the need for surge capacity and overall infection control measures. These potentially could include:
Requirements to develop multiple and controlled building entries which may be identified for “well patients” and “potentially infectious patients” to be utilized based on the reason for a visit.
Changes to the flow of patients throughout the facility. Although it is unlikely that flow in a building would be formally codified, the building code may require that facilities be able to identify separate routes for suspected infectious patients that limit cross contamination.
Waiting room size requirements may be altered to accommodate social distancing and include sub-divided spaces to segment the patient population.
Waiting room size requirements may be altered.
Modifications to HVAC system requirements to address humidity control, increase ventilation, and improve exhaust air from high-risk environments will aid in infection control. This may be a significant challenge for some existing buildings, since many mechanical systems do not lend themselves to changing functionality or control without replacing the entire mechanical system. It is more likely that newly designed buildings would be required to have more controllable HVAC systems to account for isolating and exhausting air from critical spaces.
Planning for areas within the current footprint to provide telehealth. Telehealth typically takes place where an onsite patient has access to a remote provider. The new model is one in which the patient is at home and the services could be delivered from a local or a national health provider. The difference between the two models is that home-based patients would not have access to testing, blood pressure, temperature checks, and other basic functions that take place during a traditional visit. It is likely this model of care will be expanded and become more sophisticated moving forward as an alternative for remotely diagnosing infectious patients and eliminating cross contamination.
Building design to accommodate exterior testing and triage bays. During the COVID-19 outbreak, we have seen an influx of exterior testing stations and drive-through services. This may become common for hospitals, clinics, and outpatient centers as drive-up service care delivery may become a better alternative for potentially infectious patients to reduce the risk of introducing them to non-infected patients and staff. This type of design is already used in emergency departments near hazardous chemical and nuclear facilities with a decontamination room that is isolated from the rest of the facility, allowing the initial care for contaminated patients until they can be safely admitted to a medical facility. This design could easily be modified and adopted for hospital and clinical settings to account for airborne contagion cases.
There is no doubt that the delivery of health-related services is going to change as we continue to gain insight and research from the current pandemic. Health care spaces will be designed with flexibility and functionality at the forefront of the planning and conceptual design process. We must begin thinking about worst-case scenarios and develop solutions that respond to those scenarios while implementing design principles that meet the current and future programmatic needs of the practice. If there is one thing that we have learned about the health care industry, it is that medical personnel are dedicated, resilient, and innovative. As health care designers, we continue to seek unique design solutions that respond to the needs of patients while addressing the challenges providers face to confidently and safely deliver high quality care to their patients.
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