ZIONSVILLE, Ind.—Healthcare provider Riverview Health Emergency Room & Urgent Care announced the October opening of the company’s third building that combines urgent care facilities and an emergency room under one roof. The Riverview Health Emergency Room & Urgent Care—West Carmel/Zionsville is sited at 10830 N. Michigan Road in Zionsville, which is located in the northeast suburbs of Indianapolis.

Partners on the project, which broke ground in September 2019, included E4H Architecture and general contractor Meyer Najem, the latter of which is local to the greater Indianapolis area.

Riverview’s previous hybrid care model, which has been replicated at its new West Carmel/Zionsville location, entails a 24-hour emergency room as well as an urgent care facility that operates daily from 7 a.m. to 10 p.m. In the Riverview model, patients are assessed and cared for by ER-trained clinicians, regardless of the level of medical attention they might require.

Seth Warren, Riverview Health president and CEO, said in a recent statement that as the capital region of Indiana has continued to grow in population, so too has increased the need for adequate, round-the-clock emergency care facilities.

“In just 12 months, we will have opened three new ER and urgent care facilities in three cities,” Warren said. “Our partnership with Intuitive Health is allowing Riverview Health to bring convenient care to the residents of Hamilton County.

“We are making a difference in the lives of the community we serve by providing more access and better service.”

In addition to the new West Carmel/Zionsville campus, Riverview’s other recent hybrid urgent care/emergency room facilities in Indianapolis entail Riverview Health ER & Urgent Care—Fishers, which opened last November, and Riverview Health ER & Urgent Care—Carmel, which came online this August.

Riverview also operates the combination emergency room and urgent care model at its other Indianapolis hospitals in the communities of Noblesville and Westfield. A future location will be cited in the Nora neighborhood of the metro area as well.

All such locations were built and are operated in conjunction with care provider Intuitive Health of North Texas, an early innovator on the paradigm of combining the emergency room and urgent care capabilities in the same facility. Intuitive’s medical facilities are stocked with on-site lab equipment as well as a radiology suite with X-ray and CT scanners.

“Our retail-based, combined ER and urgent care partnership with Riverview Health reflects our deep commitment to better serving the needs of patients and their families by bringing value-based care to Hamilton County,” Thom Hermann, CEO of Intuitive Health, said in a recent statement about the West Carmel/Zionsville project. “This partnership has worked mainly due to our shared value of placing patients first and prioritizing the patient experience.”

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What can we learn from Singapore’s response to COVID-19? How does it impact the next generation of hospitals?

In 2003, the small city-state of Singapore was one of the hardest hit by the SARS epidemic. Of 238 cases, 33 people lost their lives—40% were healthcare workers. This left a deep and lasting impression, with Singapore taking serious steps to be better prepared for “the next big one.” The solution: establishing the Disease Outbreak Response System Condition (DORSCON), a national prevention and response plan. The system’s color-coded framework shows the current disease situation and provides general guidelines for prevention and infection control. This plan has been tested in recent years by the MERS (62 suspected, all negative) and H1N1 epidemics with good results.

While working as a healthcare architect in Singapore from 2016 – 2019, years after DORSCON was created, hospital design and operations continued to be impacted by the program.

As soon as information emerged about suspicious cases of pneumonia in Wuhan, China, in late December 2019, Singapore started getting ready. Not only did they have a plan, but they executed it with almost military precision. In early February of this year, the country activated DORSCON Orange (second-highest level of alert), which is still in place.

Several international public health agencies, including the World Health Organization (WHO), have praised the Singapore model, some calling it “the gold standard.” Similar models were applied in Hong Kong, Taiwan, and South Korea—all countries that were also hit hard by SARS.

Let’s look at ways these countries successfully implemented public awareness campaigns and activities for the mass health crisis situations, including the COVID-19 pandemic:

Clear, transparent, and coordinated communication is provided from all government agencies such as the Prime Minister, Ministry of Health, and more. Government messaging in these countries has been consistent and transparent regarding the current situation, next steps, and recovery. This transparency builds public trust.

Public awareness campaigns were initiated immediately. They include social media, targeted informative animations, and explicit messaging about social distancing in the press.

Testing was made available early, as soon as possible after the genome sequencing became available. Extensive testing is administered in community clinics (PHPC, public health preparedness clinic), and information on where to go and what the steps are is available on websites created for this purpose, i.e. mask go where and flu go where.

The process works like this: If you have fever and other flu-like symptoms, you visit a general practitioner, who will administer a test. You get a 5-day medical certificate and go self-isolate at home until results become available (the timeframe to receive results has now been shortened to only a matter of hours). If positive, even with mild symptoms, you will be taken to a hospital via an ambulance. Separating people who test positive and keeping them under strict isolation—not at home—is key as it ensures they will not accidentally be infecting others.

Contact tracing requires a dedicated task force (over 100 investigators, including police and armed forces). As the number of COVID-19 cases grow, so does the amount of data. In an official address to the nation, the Singapore prime minister suggested that the high volume of cases could potentially be a limiting factor to the ability to contact-trace.

Within weeks, Singapore had a technology solution to address the volume concerns, the tracetogether app, launched on March 20, 2020. Asymptomatic contacts, if deemed close, are ordered to quarantine at home. Control is very strict. It leverages technology already present on mobile phones and is reinforced by random in-person checks to prevent anyone leaving their homes. Temperature checks occur regularly at the border, in schools, at healthcare providers, etc. Strict penalties are enforced for those attempting to disregard public policy, making anyone think twice about disobeying.

The key is to intervene early and act fast, from the highest levels of government. Then test, trace contacts, enforce quarantines, and require social distancing.

This disciplined approach has allowed normal life to continue during the COVID-19 pandemic for those who do not show symptoms. It keeps people out of the hospitals and enables schools to remain open (with restrictions on distancing and gatherings). This is nothing short of remarkable, for a city with a population of nearly 6 million.

Lessons Learned Designing Healthcare Facilities in Singapore

With the response infrastructure in place, we can design in support of those activities. My experience in Singapore provided valuable lessons in designing health spaces and facilities that can quickly respond in a time of crisis.

The first project I worked on was the new Emergency Department at Block H9A on the Singapore General Hospital campus. Central to their design brief from day one was “It’s not if, but when”— echoing the country’s public-awareness campaign for crisis situations ranging from health concerns to terrorist attacks—supported by a commitment to address and implement at every design stage. I learned that the same approach extended to other facilities on the island-city, following a well-defined national strategy.

The most important design aspects may not be new to a healthcare design professional. However, what sets the Singapore approach apart is the scale at which they are willing to implement and the significant amount of resources the country is willing to allocate for these efforts.

Healthcare facilities are designed with significant surge capacity and for complex surge scenarios. For example, Singapore General Hospital Block H9A Emergency Department, opening in 2023, is designed to also respond in case of a “national health crisis”—a mass-casualty incident, pandemic, or mass exposure to hazardous materials requiring a hospital decontamination station.

One characteristic of surge scenarios vs. normal operations is the ability to segment patient flows before they enter emergency departments. This is done by virtualizing self-assessment tools and non-urgent consults or visits, by utilizing external space for triage (parking lots, parking structures, etc.), and splitting the flow of febrile patients (those with fever) from the rest of the patient population—subsequently isolating them as required.

A separate entry for fever-ridden patients is created under this scenario, leading to a zone with four types of isolation rooms (contact, positive, negative, and quarantine suites). The area can treat high-risk patients while allowing the rest of the department to continue normal operations.

Compartmentalized design has the capability to isolate and lockdown the emergency department by identified zones when required, preventing the spread of high-risk infectious diseases to the entire ER. Adequately pressurized buffer zones separate the compartments and help to ensure no transfer of contaminated airflow.

Building systems are designed to support the independent functioning of compartments with a n+1 or n+n redundancy — systems offering up to 100% redundancy in air handling units, power, and medical gases. Catastrophic failure scenarios are considered as part of the design brief, driving decision making. For example: What happens if I must shut down half of any one compartment in order to perform terminal cleaning? What happens if I lose one entire compartment?

Incorporating overflow isolation and resuscitation capacity is also part of the design approach. Critical Care Area cubicles are designed with negative pressure and can handle resuscitation. The cubicles are designed as a dedicated space, bound by walls and sliding doors, to provide more patient privacy.

Trauma/resuscitation areas are designed to support double occupancy in a surge scenario.

Extensive support spaces offer room for staff reporting for work shifts in a surge scenario, as well as ample storage for needed supplies and equipment. Staff respite areas can then be created by converting administrative space.

Contingency plans can expand beyond the emergency department to associated specialties like radiology, ICU, IPUs, etc.

I expect that in the aftermath of the COVID-19 crisis, the way we design healthcare spaces will be forever changed. It will start with how we deploy virtual care. Beyond that, we will see more focus on designing facilities for resilience and increased responsiveness.

Healthcare is a global concern. If we want to keep people safe and save lives, we need to look to the crises we’ve encountered before for learning and inspiration.

Maria Ionescu is a senior healthcare architect for Stantec, based in Los Angeles. Growing up in Romania, Maria was exposed to both Western and alternative types of medicine. At Stantec, she leads the development of highly integrated healthcare campus facilities that include natural gardens, peaceful multi-purpose spaces, and a variety of diverse practitioners.

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The expansion includes a new design and layout for the hospital, with new equipment to promote better patient flow and access, as well as includes an open and spacious refurbished lobby. To appeal to children and families, a children’s play area was installed as well. Additionally, the triage and help desk were redesigned to increase visibility of staff for incoming patients and families.

Three rapid assessment zone bays – where ambulances drop patients off – were added in an effort to promote the quick and easy transfer of patients arriving by ambulance. In the short time these new zones have been in use, there has already been a significant reduction in ambulance waiting times, according to Hospital General Manager Shelley Hancock, who was also on site at the open ceremony.

In a similar effort, four new treatment chairs to service waiting room care and promote early assessment and care for walk-in patients and ambulance arrivals were added during the expansion. “The changes to the emergency department (ED) mean more patients will hopefully wait less time to be seen,” said Hancock in a recent statement.

The Shoalhaven region has experienced a growing demand for health services in recent years, according to South Coast Parliament Member Gareth Ward, who attended the hospital’s opening ceremony. “We have seen an increase on the number of sicker patients presenting to the hospital particularly over the past 12 months. That is why we pushed for this development to build up some capacity and improve performance,” Ward said. “The transformation of the ED and the revamp of a number of the hospital’s facilities will help to improve the flow of patients through this very busy area.”

The new hospital expansion is described as a “welcoming environment,” according to Hancock, and is part of a $5 million overall hospital improvement project, which included the addition of the Shoalhaven Cancer Care Centre in 2013 as well as plans for a new parking lot on campus.

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The hospital’s emergency department was originally built to serve 35,000 patients. The increase in patient traffic at the Augusta Health ER over the past 20 years has led to patients often being served in hallways or corridors during especially busy times. “The hospital is not only seeing more patients, but patients of higher acuity with trauma, strokes and heart attacks,” said Mary Mannix, Augusta Health president and chief executive officer at Augusta Health, in a recent statement.

The addition and renovation will allow the hospital to expand and grow as the community it serves does the same, according to Mannix. The current space constraints of the hospital limits its ability to accommodate and upgrade to the significant innovations in medical equipment and technology in recent years, and the intention of the hospital’s expansion is to make these upgrades possible.

The plans for the expansion include a 33,000-square-foot, two-story addition, as well as renovating the existing 17,500-square-foot facility. Completion of the project is set for 2019. The expansion will include 48 large, private rooms and dedicated areas for stroke, heart attack and other trauma cases. There will be areas for family consultation, private conversations and for meetings with doctors. Enhanced workspace for EMS, police and mental health professionals are also included in the plans for expansion. A new ambulatory entrance with a canopy will also be built, and 16,288 square feet of shelled space for future use are included in the expansion.

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