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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When the image of a hospital comes to mind, most envision a similar setting: fluorescent lighting, various mechanical noises, white tile floors, eggshell painted walls and the smell of disinfectant. For some visitors, these environmental components can evoke feelings of unease and even anxiety.

This however could be changed by biophilic design, a practice slowly gaining momentum in medical facilities. Biophilic is derived from the term, “biophilia,” meaning “the urge to affiliate with other forms of life.” This term introduces the idea of incorporating natural materials, light, views and vegetation into the modern world.

Singapore’s Khoo Teck Puat Hospital (KTPH) KTPH, Ng Teng Fong General Hospital (NTFGH) and Jurong Community Hospital are the only hospitals considered to have an extensive biophilic design in Asia. As research has linked green buildings to positive effects on people’s health, more studies are needed to determine the link between biophilic design and patient recovery in healthcare settings, according to Prof. Lam Khee Poh, dean of the National University of Singapore’s School of Design and Environment. However, these studies are limited as few hospitals worldwide have such designs, he added.

The ultimate goal of this design is aimed to influence patient and staff’s psychological and physiological response to their own space, further creating a more helpful healing environment and reducing the length of patient stay.

The first example is KTPH, a $700 million, 590-bed general and acute care hospital, which opened June 2010, and includes 10,957-square-feet of greenery, winning the inaugural Stephen R. Kellert Biophilic Design Award Dec. 2017 for its exemplary plant and water features. Its design infuses a rainforest-like atmosphere with a cascading waterfall flowing into a central garden courtyard, rooftop gardens and planter boxes along corridors and outside wards provide patients with green views, and the hospital grounds even open out into Yishun Pond. The hospital’s public areas are also naturally ventilated by louvres on the facade which channel wind throughout the interior while blocking out direct sunlight, according to a statement.

With these features, the “sterile” sensation of a hospital can be mitigated, creating something more pleasing to all senses with the sight of lush green, sound of flowing water and the smell of fragrant plants.

Another example examines NTFGH and Jurong Community Hospital, which the design process being pushed by the idea of creating a healthy and healing environment for patients, said Mr Foo Hee Jug, chief executive officer of NTFGH, according to a statement.

Built in June 2015, the combined 1,100 room, $461 million pair of hospitals, which are managed by JurongHealth, have won several awards for design and environmental sustainability, including the American Institute of Architects Committee on the Environment Top Ten Awards in 2017. The hospitals’ fan-shaped wards with windows for each patient increase ventilation, with planters providing a green view. There are also 15 gardens, including one for intensive-care unit patients, and ward towers are orientated to optimize day lighting while reducing glare. Staff are also not forgetting about, with a light well providing natural lighting at a relaxation area for backend staff who work in the basement.

Since adopting this design, KTPH has achieved 33 percent less energy use than that of conventional hospitals, with NTFGH and Jurong Community Hospital reducing energy use by 30 percent, more than $5 million savings in electricity bills, and nearly $100,000 in water savings.

But, there are still challenges in implementing biophilic design, not least as many healthcare institutions are still largely seen as sterile environments, and there are concerns about increased maintenance cost. An increase in pests like insects and the amount of dead leaves, which can clog up drains, are examples of the problems that some hospitals would rather avoid, says KTPH director of hospital planning Donald Wai, according to a statement.

KTPH uses neem oil, an non-toxic organic substance, on the plants so as to deter pests.

“I feel that the management of each healthcare facility needs to embrace this green philosophy,” said Wai. “The biophilic environment is not just meant to allow patients to walk about, feel relaxed and to recuperate, but also to make our staff feel that they are in a very calm and relaxing environment.”

Prof Lam adds that he believes there is a good chance that biophilic design can have a long-lasting impact on health.

“To me, it’s not so much the cost but what value are you getting out of it. If you invest well, you’re going to get the returns many, many times over,” Lam said. “And if you design it well and integrate it well from the beginning, it doesn’t necessarily mean that it will cost a lot more.”

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