As we enter year two of the global pandemic, there have been transformations in healthcare delivery. Practices that were once on the periphery, such as telemedicine and touch-free check-in, have become routine even for many patients who might have resisted them in pre-pandemic times.

At the same time, health providers were forced to quickly redesign layouts of their facilities because of new requirements for social distancing. Post-pandemic, Simone Healthcare Development, as a leading developer of healthcare facilities for major medical providers throughout the Northeast, expect most health providers to convert many of the temporary social distancing measures into permanent policies.

In the short term, social distancing reminders like floor markers and hand sanitizer stations will remain. As health providers turn to longer-term and more expensive social-distance solutions, we will see an overhaul in waiting room design, as providers replace old furniture with seating that is easy to reconfigure, clean and disinfect. Waiting rooms may also expand, as the need to accommodate safely distanced patients continues and many physicians are permitting patients to wait in their cars and call when “the doctor is ready.”

In future construction or renovations, we may see buildings with wider hallways or multiple, one-way hallways with doors or turnstiles that only permit one-way entry or exit. More examination rooms and waiting rooms will become negative pressure environments. The need for negative pressure will require enhanced ventilation systems with new air-filtering technologies.

Despite adjusting to these new realities, many providers face the continuing challenge of consolidating a number of medical practices into one multi-specialty location to benefit patients and medical staff, create efficiencies and provide seamless care. The challenges of such projects are complicated but achievable, and we expect this consolidation trend to continue for the foreseeable future.

A good example is a medical practice consolidation project successfully completed by Simone Healthcare Development for the Mount Sinai Health Network. When assigned by Mount Sinai Long Island Doctors to find a location for a building that would consolidate their many practice units in the Huntington, Long Island area, Simone Healthcare Development took on the challenge. Simone Healthcare led the effort to source and acquire the property, secure approvals for zoning, site plan, and change of use to a medical office building for 5 Cuba Hill Road in Greenlawn, N.Y. Now in full operation, this Mount Sinai Long Island Doctors location will have 200,000 patient visits per year, clear proof of its value to the community.

The consumer push to lower medical costs will also continue, causing a proliferation in out-patient services and medical procedures. A growing aging population is also driving profound change. Today there are 50 million people in the United States over the age of 65. In the next 10 years alone, the over 65 population is going to grow by 20 million people. We must become more efficient and effective in treating this aging population.

As an example, by 2030, the number of primary total knee replacements is expected to increase by 673% to 3.48 million procedures annually, and the number of primary total hip replacements will increase by 174%, to 572,000 procedures annually. As the population ages, more people develop arthritis of their joints and problems with their spines. We are now more active in the later years and sustain similar injuries of younger people. Osteoporosis which affects older men as well as older women, leads to an increase in fractures, especially in the spine and hips. Each year, approximately 300,000 people fracture their hips because of osteoporosis.

To accommodate the growing preference for day surgeries and avoiding hospital stays, the trend toward the “bedless” hospital continues as well, such as the facility that Simone Healthcare built for Montefiore Medical Center in the Bronx where a patient arrives for a procedure in the morning and leaves later in the day. Continuing strides in technology and healthcare now require a lot less patient recovery time.

The concept of ambulatory care is taken to new heights with this 280,000-square-foot “bedless hospital” custom designed for Montefiore Medical Center. Located at the Hutchinson Metro Center campus, the 11-story tower includes 12 operating rooms and four procedure rooms, an advanced imaging center, onsite laboratory services and pharmacy, as well as new primary and specialty care practices. From the moment you enter the elegantly designed lobby, you sense a healing environment that provides patients with a positive experience while offering an array of medical services in a central location including primary and specialty care visits, diagnostic imaging and surgery. The interdisciplinary approach to care — with doctors, nurses and technicians all located on the same floor — allows for stronger, easier collaborations and referrals.

Another of today’s most important technology trend is how Artificial intelligence (AI) will transform how healthcare is delivered. He said AI will help increase productivity and the efficiency of care delivery and allow healthcare systems to provide more and better care to more people.

In addition, the huge growth under way in biotech and life sciences will have tremendous impact on healthcare. Outpatient and urgent care facilities will continue to grow, as will the use of telemedicine.

Meeting the challenges of future healthcare delivery requires a close and trusting relationship between developer and healthcare provider and a shared future vision of excellence in healthcare delivery. At Simone Development, we welcome this transformation in healthcare delivery because all patients deserve peace of mind when seeking essential care and preventive medicine.

Guy Leibler is the president of Simone Healthcare Development.

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Context and Challenges

Facing overburdened capacity at many of the nation’s healthcare facilities is not a new experience, healthcare leaders are driven to expand facilities to accommodate population increases—while lacking the funds to do so even before COVID-19 existed. The resulting balance between space, and the costs of building and maintaining it, can often feel like a tightrope.

Frequent changes to reimbursement rules are just one part of the equation. ER visits fluctuate, trending down as the number of patients with insurance increases, then upward again as coverage decisions are reversed and insured patient populations fall. Demand on the ER system and the associated billing changes in a pandemic also dramatically impact facilities.

Additionally, urgent care clinics are seeing higher usage as population demographics change. On-demand care appeals to a growing number of patients who would rather see a doctor when it’s more convenient for them (e.g. weekends), than make an appointment and take off work.

At the same time, leaders are concerned with COVID-19 and the already ongoing changes in rulings from the Centers for Medicare & Medicaid Services (CMS), making their prospective payments unreliable, which puts a further strain on healthcare systems.

Both space constraints and funding challenges are closely interrelated, as many systems and providers simply don’t have the budget to expand their facilities to meet growing demand. This is especially true in California, where the cost of building new facilities is much higher than the national average. Budget is also a new struggle as hospitals where forced to cancel elective procedures during the pandemic, many of which help significantly fund a number of hospitals.

To address these challenges, leaders can look to examples where creative planning, good change management, and rethinking space and resources helped to balance costs and improve efficiencies.

Planning, Change and Collaboration

Creative, Savvy Planning. Creative, savvy healthcare planning offers a path forward. Thinking outside the proverbial box yields flexible solutions that enable leaders to do more with less.

Multipurpose spaces, such as ER swing spaces, offer an excellent example to consider. A triage room could be used as a two-bed patient room in a situation like a flu epidemic, where unmanageable numbers of people would otherwise sit in the waiting room. Opening a triage room can get patients into a bed for observation, fluids, and either admission or release to help unburden the waiting room.

Exam rooms that can also be used as consult rooms are another example of expanded use through flexible design. However, while exam rooms can be dual purpose, there is less opportunity to co-use inpatient rooms because turnover is very high. One way to combat this is to create a wing that is flexible in influx situations like the pandemic. If you could flex a medical surgical unit to a slightly smaller number of negative pressure isolation rooms in less than 24 hours would that be worth the initial HVAC upgrade costs?

One solution is to co-host ancillary services. For example, a behaviorist and a nutritionist, each of whom are only on site one or two days a week, can share an office.

Selection. Despite the need to streamline operations and improve efficiency, significant changes that affect staff can understandably result in resistance. How leaders respond depends largely on organizational culture.

Some cultures have a very strong leadership decision-making component, while others have a more grassroots, inclusive decision-making component. Both have advantages and disadvantages.

When an organization is inclusive, group collaboration approaches offer more advantages. Changes come from front-line staff providing care and services, and as a result are more incremental, making it easier for staff to adapt. Inclusive managers are considerate of the front-line staff, and, therefore, receive more feedback. Although the amount of feedback can be considerable relative to a dominant management culture, the outcome is more input allowing for more informed decisions.

Therefore, wisely assembling a group of decision makers to come up with an effective strategy for developing solutions and implementing changes requires careful selection. These candidates are willing to look at a variety of options. They also value each individual as a professional, not just a commodity, to reach the ultimate goal of great patient outcomes.

Furthermore, group members must be open to change and excited to explore new ideas. It is important to have a balance of participants who have several years’ experience and really understand the way the facility works, with participants whose careers are ahead of them and who will be around to see the plan come to fruition.

Whatever the group’s makeup, putting an array of people with different perspectives in a room together to navigate operations and create strategies that can be replicated is an effective solution. However, with a diverse group that provides thoughtful input, it is infinitely more important to get approval on a final solution.

Using a lean tool – choosing by advantages, for example – can be a way to regulate emotions, come to a group decision, and help garner that final approval. Another way to aid consensus is for the team to focus the decision tree on a certification system like Planetree International, which is designed for patient centered care.

Collaboration. Collaborative planning results in a solution that has the intrinsic endorsement of the cross-functional team who were key to its creation. However, even effective group-generated solutions must be progressively implemented, in incremental steps, to ensure widespread acceptance and implementation.

When care providers and staff who are affected by new solutions and policies are consulted ahead of time, they are more likely to recall their buy-in when the time comes for the new approach to be broadly implemented and therefore advocate for it.

One way to achieve buy-in is by harnessing the benefits of virtual reality (VR) technology. Staff can virtually experience their daily routine in the new space. The ability to visualize and experience the space completely transcends the effect of viewing plans and drawings and can advance the conversation for employees who may be understandably resistant to change. In this way, VR training can be a powerful means of planting the seeds of change before the project is built.

Solutions and Strategies

Process changes. Process changes such as virtual check-ins, combining services, and telemedicine, among others, can be a huge differentiator in the efficient use of space balance.

Streamlining the patient intake process is one way facilities can save space. If patients can check in virtually, perhaps even before they arrive at the facility, this frees up resources to treat patients.

In rural hospitals, where staff is often overstretched and under-resourced, combining and collocating departments to share nursing services can reduce the number of full-time workers on the payroll during the less active overnight hours, while still satisfying laws regarding the number of patients per caregiver.

Telemedicine is another emerging, though quickly growing under the pandemic, change that can make a significant difference for rural hospitals. When patients are referred to a specialist, but the nearest practitioner is miles away, holding a video consult with the specialist at their primary care physician’s office may be sufficient for a diagnosis. This appeals to both patient and provider because it not only saves the patient significant time and cost; it also improves provider efficiency.

Centralized versus decentralized nurse stations. When the debate focuses on centralized versus decentralized nurse stations, the conversation ultimately is about whether staff are willing to invest in enhanced circulation.

A transparent discussion about what people see on a daily basis and how they can improve flow will result in a solution that works for everyone, even if that is a hybrid between centralized and decentralized stations.

Storage. Another kind of flow improvement can come from choosing a time-saving storage solution. In one hospital, for example, IV supplies needed to administer patient medications were kept in a clean supply room. Nurses and providers had to constantly enter the room to pick up needles, IV bags, poles, and so on.

In the past, they carried the materials to a medication room, which lacked adequate work surface space to place supplies and access medications. For this provider, moving the IV supplies to the medication room was a simple, clear solution that saved time and reduced frustration for everyone.

Pharmacy plus lab. Pharmacy and lab groups are often among the most willing to talk about possible solutions for process and layout changes.

In one example lab, two people worked overnight, and eight people during the day. The team sought a solution that was comfortable for both, where the two-person overnight crew would feel safe and not have to travel long distances, while the eight-person day crew wouldn’t feel unnecessarily constrained.

The employees talked about flow and optimizing functionality together. They arrived at a bench layout that worked for both groups, moving things that were accessed less frequently—like printers—above or below the main counter to free up space.

At the same time, the solution consolidated other functions to make smaller spaces easier to use. The group located the overnight functions more centrally, promoting better visibility and security for the overnight crew without compromising the workflow of the eight people during the day.

Standard care model versus modern on-stage/off-stage exam clinic. In another example, an outpatient clinic was switching from a standard care model to a more collaborative on-stage/off-stage exam clinic approach.

A building shell was completed on a traditional clinic layout; however, the new on-stage/off-stage approach required more square footage to accommodate the new clinic module.

The solution involved reducing the pediatrics area, as well as sharing spaces that were not used full time. These included geriatric rooms, internal medicine, etc.

A total of eight exam rooms were ultimately removed from the total project, and the reduction allowed the system to avoid removing a complete service line.

In addition, staff were given shared workspace in the central staff support area, with two to three employees rotating through one shared space rather than individual offices. The staff area’s central location provided mobility to quickly see patients in the unit.

The Bottom Line

Balancing cost. While efficiency and ease of use are key components, the impetus for these solutions is balancing costs.

Redesigning an area to optimize performance often means allocating less square footage and fewer employees to reduce operating costs.

For example, employee salaries are the most significant part of the operational budget. If it’s possible for part-time employees or those with shifting tasks to share spaces and resources, the reduction in overhead can help finance future expansions as the community grows.

When expansion does become necessary, creative and savvy planning can substantially impact the operation and construction bottom line. Still, it’s important to be mindful of scope.

For example, when studying the feasibility and impact of a new ultrasound machine, decision-makers must consider all real costs—not just the machine itself, but also construction and installation costs. Starting with awareness of those kinds of additional costs saves time in the overall analysis.

Speed to market is another cost-savings driver: the faster a facility can open, the less it will be subject to the disruptive influences of escalation and market fluctuation, and the more quickly it can start generating revenue. With construction prices continually increasing, quick, decisive action to plan and implement new strategies is especially key.

Involving the key decision makers and getting that final buy in is paramount to successful project execution. The best way to optimize the budget is by engaging stakeholders early on to determine where it’s possible to save on space, cost, FTEs, and resolving these issues in design.

Overall, committing to and executing a project requires smart and thoughtful planning that optimizes the project’s success while navigating the space and cost tightrope.

Kelly Schreihofer, AIA, is an associate medical planner with Architectural Nexus.

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The coronavirus entered the U.S. in January 2020, and by March, the virus virtually shut down the entire country. All over the world, the pandemic-induced “new normal” has caused nations and its residents to rethink and adopt novel social and health protocols. The healthcare and construction industries were at the forefront and, in many cases, had to be the nimblest to react and lead within the new direction.

COVID-19 and the way people view daily habits, environments, interactions, and overall safety will remain a reality for years to come. The necessary reassessments must be reflected in the stipulations for immediate protection and to prepare for the next widespread health emergency or natural catastrophe.

Hospitals have long been acutely designed to mitigate infectious diseases. Also, the success rates in safely treating patients are increasingly high when proper behaviors are used and access to enough personal protection equipment (PPE) is not in question. However, it’s clear those factors aren’t enough to put patients’ and employees’ concerns brought on by the current unprecedented pandemic at ease.

Designing for the New Normal

Planning healthcare facilities in a post-COVID world could include complex operational and infrastructure design considerations. An immediate concern is for hospitals to keep elective, or necessary but not life-threatening, surgery cases going while dealing with overflowing emergency departments and intensive care unit beds. The challenge is making patients feel comfortable to have surgery during a pandemic. For example, a few months removed from the spike in coronavirus cases in New York, hospitals are still not seeing patients return, and most procedures are only back to 50% to 70% of what they were. In response, medical centers are already implementing design and staff reconfiguration plans to create segregated areas within certain units or adjacent to the main hospital to ensure fluidity and increase patient satisfaction.

For the long term, hospitals must take a hard look at prioritizing infrastructure upgrade projects. Building new HVAC (heating, ventilation, and air conditioning) systems and improving the medical gas infrastructure may not have a significant return on investment at first blush, but will be factors patients start to measure when deciding where to have treatments done. It will likely become the norm for a patient to ask about the surgeon as well as HVAC systems, and maybe not in that order.

Healthcare systems are also considering micro hospital development with urgent care and inpatient capabilities on a smaller scale. Additionally, expanding services to more rural catchment areas is being explored to get treatment options closer to patients while alleviating the overflow of the main acute care hospitals. Going forward, hospitals may move more services that must continue regardless of a pandemic (i.e., childbirth) out to an ambulatory or free-standing center model.

Some of the supply chain, speed-to-market, and labor issues the healthcare construction industry continues to experience has sparked new discussions on alternative development, such as increased consideration for modular solutions, which the medical sector has previously been slow to embrace. As the construction industry faces a potential decline in skilled labor, modular lends itself to cross-training, which cannot happen on a traditional commercial project site. Benefits also include controlled construction environments, waste reduction, and quality control, all of which create tremendous value.

Adjusting to Evolving Construction Guidelines

While it’s interesting to consider how healthcare design could potentially change forever, project managers currently grapple with construction challenges due to frequently changing guidelines that vary from city to city. The requirements remain unclear, and thus, the safety of workers is the concern and main priority. At the same time, adjusting to new rules almost daily continues to cause delays as substantial as the shutdowns, further postponing the delivery of much needed medical space and economic recovery.

In most metro areas, new guidelines require additional staff on all projects to check in on workers and ensure that protocols are being followed. For example, in New York City, managers must maintain contact tracing and cleaning logs, take workers’ temperatures, provide specific signage, and make sure social distancing is in place. Shift work has been implemented at some sites to allow for social distancing. In this situation, separate entry and exit points are designating for the shift arriving and the shift leaving, which sometimes creates long lines of workers that span entire city blocks awaiting site access.

As aforementioned, the healthcare construction industry is also experiencing a decline in available skilled labor. Some tradesmen don’t want to come back to work due to COVID-19 concerns, and others are making as much or perhaps more money staying home with the increase in unemployment benefits. Supply chain issues also persist with the unexpected closures of manufacturing plants in different parts of the U.S. at times.

Despite the many challenges, healthcare system managers and construction consultants are working diligently to reimagine medical facility designs for the future while mitigating today’s ever-changing construction guidelines. One thing is for certain; there will be significant changes coming, and the healthcare industry will be at the helm. 

Richard Simone is CEO and president of Central Consulting & Contracting, a full-service construction management and general contracting company that specializes in healthcare facilities. He has over 35 years of experience in the construction industry. Central Consulting & Contracting has worked with many major healthcare systems across the U.S. East Coast on complex projects from hybrid robotic operating suites to ground-up development and facility planning.

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OAK BLUFFS, Mass.—Nearly 7,000 square feet of underutilized space at the Martha’s Vineyard Hospital have been renovated and repurposed during the coronavirus pandemic, the medical center recently announced.

The redesigned space will provide extra space for the hospital’s primary care center, which services the small island community’s year-round residents as well as its traditional influx of summertime visitors. Due to the island’s increased visibility and desirability as a tourist destination, the hospital also needed to be expanded—while simultaneously protecting the community’s limited space and wish to maintain its traditional ways of life.

In keeping with the desire of the community to ensure that the hospital maintains its look as part of the island’s infrastructure, the design motif for the expanded wing employed a nature theme. Accordingly, the colors, sounds and lighting in the reconfigured lobby evoke the sand, water and stone that are so much a part of the island’s topography and surroundings. As patients and their families await consultations in the hospital’s lobby, they will be bathed in natural “light fills.”

Arrival at the hospital has also been set up for ease of access, such that the rear parking lot allows direct ingress via a walk-in entryway. This is meant to foster a greater feeling of accessibility for new arrivals and be more welcoming than a more typical healthcare entryway.

The repurposed wing at the Martha’s Vineyard Hospital features 16 entirely new examination rooms as well as office areas for care providers. The main feature of the renovated space is the

MVH Primary Care Internal Medicine Suite, which expands the amount of healthcare space and capabilities for treatment that are available at the hospital.

Furthermore, the new layout allows for doctors and nurses to be working in contiguous offices rather than being spread apart within the hospital setting.

Martha’s Vineyard Hospital president and CEO Denise Schepici and Hospital Facilities Director John Murray worked on the redesign in conjunction with officials from the Boston offices of the architecture and engineering firm HED.

Less than 20,000 people live on the island year-round, but the population can grow far larger during the peak of summer tourism.

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BILLINGS, Mt.—Architecture, engineering, and design firm Cushing Terrell has developed what it calls a negative air pressure ventilation system designed to help prevent the spread of coronavirus infection between patients and healthcare workers. The firm recently worked with longtime client Billings Clinic to convert 100 patient rooms for the new paradigm, with a representative of the company saying Cushing Terrell “re-engineered, air balanced, and specified new supply and exhaust airflow for several bed floors in the hospital.”

In a recent interview posted on Cushing Terrell’s website, mechanical engineering group lead Shawn Murray said that it was critically important to create environments where covid-19 patients could be effectively treated while simultaneously keeping the possibility of infecting other patients and medical staff down to an absolute minimum. Accordingly, the firm’s negative pressure rooms are meant to contain, within a limited space, a patient’s exhalations since the main way that the coronavirus is spread from person to person is via airborne particles.

Murray said that the most effective way to treat covid patients would be to isolate them for treatment in “airborne infection isolation” (AII) rooms, but he added those rooms are extremely rare anywhere in the healthcare field. Accordingly, healthcare spaces that already exist would need to be “converted” to allow for negative air pressure situations.

“Air from these rooms does not recirculate into other areas of the hospital and is exhausted via dedicated ductwork where it is diluted in the atmosphere,” Murray was quoted as saying in the report. He added that patient rooms need to be quickly converted for negative air pressure given the ongoing nature of the pandemic, and should a future spike occur in Montana.

Although Cushing Terrell, which has many offices outside of their founding location in Billings, has performed work of this type on many other projects before, Murray’s contention is that this was the first time his company needed to simultaneously convert so many “standard” patient rooms for negative air pressure. In their writeup, Cushing Terrell quoted Murray as saying it was incumbent to “reconfigure enough rooms on the ICU floor where the intubation and extubation of ventilators for critical patients could create the highest risk for transmission to other areas of the hospital.”

This required overriding dampers on the air-handling units such that air which circulated throughout the patient rooms would instead be redirected directly to the outdoors. Murray said that this effectively changed the patient room “inlet air grilles into exhaust grilles” at locations throughout the Billings Clinic, including at nurse’s stations. Furthermore, certain inlet air grilles at the clinic were blocked such that additional exhaust air would be extracted from patient rooms, and thus “create a positive flow from the caregiver area into the patient rooms,” as Murray put it.

“Door sweeps” on patient doors were installed so that pressure differentials between patient rooms and the adjacent corridors could be equalized as well.

Murray added that one of the biggest challenges of the installation of the air pressure system was to foster a way to keep an operating room “positively pressured” along with the main surgery corridor, while rooms adjacent to the operating room had air in them that remained sterile. As such, one entrance had to be sealed and airflow redirected through what became the new anteroom outside the OR.

Murray said the project at the Billings Hospital also gave his firm a better idea of what future adjustments and improvements might need to be made to the HVAC system at the clinic.

Cushing Terrell has worked on air circulation and ventilation for various projects around the country. The firm was founded in Montana in 1938.

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WASHINGTON, D.C.—Healthcare construction company Hoar Construction, which is based in Birmingham, Ala., but also has offices in the capital region, has been providing free meals to hospital workers in the Washington, D.C., area, according to Tysons Reporter.

This resulted from a rather fortuitous partnership as Mike Dramby, Hoar Construction’s senior project manager, is based at the firm’s office in Tysons, Virginia, and has been lifelong friends with Bryce Yetso, the general manager of Clyde’s, a restaurant with several outlets throughout Virginia, Washington, D.C., and Maryland. The two jointly came up with the notion to provide meals to overburdened healthcare workers in the capital area, who have been battling the coronavirus pandemic.

According to the Tysons Reporter story, Dramby himself has worked for years on hospital construction for Hoar and was thus intimately familiar with the burdens facing healthcare workers, especially in the D.C. region.

Furthermore, because the Clyde’s chain was forced to lay off much of its workforce in light of the pandemic, Dramby and Yetso found a way to get some of those laid-off food service workers back on the job with their newfound focus on feeding healthcare workers. Given the two men’s long friendship and connections in the region, they were able to quickly mobilize the operation to feed as many healthcare workers as possible in a short time.

Hoar’s work on the project entailed fundraising and coordinating with the local hospitals for meal deliveries that had been prepared by Clyde’s staff, Tysons Reporter said, and also reported that Dramby’s coworkers at Hoar also contributed time, effort and fiscal muscle to the joint effort with the restaurant company.

The pair say they hope to soon expand the joint effort to other hospitals in the capital region.

Meanwhile, Hoar’s workload on healthcare construction hasn’t slowed during the pandemic. Tysons Reporter said that Hoar has actually been busier of late given that multiple hospitals and other healthcare facilities are adding wings and converting certain areas to specifically deal with coronavirus patients.

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STONY BROOK, N.Y.-As hospitals in the greater New York City area, which has been the epicenter of the United States’ epidemic of the novel coronavirus, have been operating at or above capacity for many weeks, officials in Albany have been scrambling to increase the Empire State’s available number of hospital beds for the treatment of patients suffering from COVID-19 as the pandemic continues. Accordingly, a “temporary” hospital is under construction on Long Island, at the University of New York Stony Brook campus, located approximately 60 miles east of New York City. Thousands of New York residents are doing everything they can to reduce the chance of contracting Coronavirus, like getting face masks from custom lanyards 4 all, social distancing, and only going out when necessary. However, there are still a lot of confirmed cases, hence the need for a temporary hospital. The number of cases is also increasing.

The new hospital facility at SUNY Stony Brook will have capacity for approximately 1,000 beds. The facility has been fast-tracked following Gov. Andrew Cuomo and other civic authorities pushing for as many beds and treatment options as possible to treat those suffering from covid-19. The United States Army Corps of Engineers has been hard at work on building out the new hospital since construction work began on the new emergency healthcare project on March 29.

The project at SUNY Stony Brook is being built out on the empty soccer and softball fields located behind the campus’s LaValle Stadium on the north side of the campus, according to a report in Untapped New York, and offers relatively quick access from the Long Island Railroad station at Stony Brook. The report said the site was ideal given its remoteness from academic buildings and residential halls, and the fact that the fields are not currently being used as activities like sports have been canceled.

Earlier, the Jacob K. Javits Convention Center in New York City was repurposed solely for covid-19 patients, which helped increase healthcare professionals’ ability to deal with the crisis in the city, but more capacity was needed throughout the state, Cuomo said.

In addition to relieving some of the pressure on New York City, Cuomo said that the greater Long Island area would rapidly run low on its capacity to deal with the pandemic without projects such as the SUNY Stony Brook hospital.

“Long Island does not have as elaborate a health care system as New York City. We don’t have the same amount of resources on Long Island, and we see an increase in the number of cases on Long Island, and that has us very concerned,” Cuomo said on April 3, as reported on the official website for the governor. ”

In addition to the project at SUNY Stony Brook, other fast-track temporary hospital projects are planned for Westchester, Rockland, Nassau and Suffolk counties, all of which neighbor New York City. Additionally, there will be similar projects at SUNY Westbury and the Westchester County Center.

New York states has 214,000 cases of the novel coronavirus, with 10,367 deaths in New York City alone, NPR reported.

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I spend much of my life thinking about hospital design. And these days, with the outbreak of novel coronavirus (COVID-19), I’m sure many people around the world are looking at their hospitals in new ways, as patients and staff try to stay healthy. COVID-19, declared a pandemic by the World Health Organization (WHO), has brought hospital design and infection control to the forefront.

My colleagues and I are currently looking at pandemic management best practices from around the globe, such as the approaches Singapore implemented after the SARS (Severe Acute Respiratory Syndrome) epidemic in 2003. Strategies from countries like Singapore can be used—and some practices already have—in North American and European hospitals. What we’re learning is that we should be looking at several specific approaches now and moving forward, to help ensure that we are planning for and able to manage current and future health crises.

In Canada, there have been significant strides toward building preparedness into our hospital designs since the SARS outbreak hit Toronto. A key element of preparedness is the ability for hospitals to retrofit or reallocate parts of their facilities, accommodating worse-case scenarios such as a serious outbreak. Here are four ways that hospitals can act now to alter their buildings for pandemic response.

1. Including separate emergency entrances for contagious patients

One of the biggest risks of an infection infiltrating a hospital system occurs when people walk in but don’t realize they’re sick. At the point of entry, healthcare staff need to be able to screen people.

Conventional: Normally, patients can find the emergency department by walking in the hospital’s front doors or the emergency entrance. But if someone is feeling symptoms of COVID-19 and they arrive at the main entrance and wander around the hospital first—perhaps looking at a map of the hospital or buying a coffee—they could be coughing or touching numerous surfaces, leaving a trail of infection in their wake.

Pandemic response: Separate the emergency entrance, so people with COVID-19 symptoms stay away from the main doors. You don’t want patients who are visiting the hospital for other issues—such as broken bones, or other non-contagious injuries or issues—sharing the same space with patients exhibiting COVID-19 symptoms. Having a separated emergency entrance for contagious patients, particularly those with fevers, enables hospitals to stream patients there first for screening before entering other areas of the hospital. Hospitals can also incorporate another entrance with negative-pressure isolation rooms at emergency for patient transfers, where an undiagnosed patient who may be infectious is contained before moving further into the hospital environment. This enables hospital staff to diagnose and then, if necessary, prepare the path to a negative-pressure isolation room.

2. Transforming hospital lobbies—as well as other external spaces—for patient prescreening

Existing large spaces can be valuable in a pandemic scenario. Large main lobbies are sometimes criticized as a luxury, but in a pandemic, they can be converted into mass screening triage areas. External spaces—like parking areas—can also be used for prescreening but should be considered a last resort.

Conventional: Typically, a hospital lobby welcomes visitors while offering retail and providing wayfinding assistance. The lobby may also serve an important community function, where it resembles a town square and provides a space for residents to meet and interact.

Pandemic response: By adapting a lobby for mass screening, it can relieve the stress imposed on the Emergency Department so that the department doesn’t become overwhelmed. Newer hospitals will likely have lobbies with electrical and IT services support. As a secondary option, a hospital parking lot—or potentially a parking structure adjacent to the hospital—can provide opportunities for prescreening. This way, healthcare staff can ensure patients are going to the right place and not adding to cross-contamination. Ideally, an internal space like a lobby is a better option, so healthcare teams don’t have to deal with outdoor conditions, especially during the winter in many North America cities.

3. Controlled separation between patients, visitors, and staff, based upon specific illnesses and their related level of contagion

With screening at hospital entries in place, it’s key to be able to manage “on stage” public access to each department while maintaining separate “off stage” service flows necessary—e.g., the “behind-the-scenes” areas of the hospital—for continued operations.

Conventional: Usually, it’s desirable to offer public access to most departments.

Pandemic response: When dealing with a pandemic, it’s important for healthcare professionals to manage who comes into a given area. Staff members need to have the ability to keep visitors and other patients away from specific areas. If possible, public access should be restricted. At this point, the Public Health Agency of Canada advises healthcare professionals to limit the number of visitors to those who are essential (such as an immediate family member or parent, guardian, or primary caregiver), and limit their movement within the hospital by only visiting the patient directly.

4. Providing the ability to convert existing hospital spaces—during a pandemic—into patient treatment spaces

Healthcare staff know that inpatient units and rooms are designed to contain and control infections. But in a pandemic situation, modifications may need to be made.

Conventional: Staff will have access to Airborne Isolation Rooms (AIR)—which contain vestibules and filtered air to eliminate transfer contamination through the hospital—for patients. And even in regular patient rooms, underlying engineering systems should be designed to maintain the room at negative pressure to the adjacent corridor. This supports infection control so that germs from one infectious patient are not “blown out” to the rest of the unit.

Pandemic response: If only a portion of the rooms on a floor are AIR, in the case of a pandemic, staff should have the ability to convert regular patient rooms—or even a whole unit, if needed—into an isolation zone. Ontario’s Ministry of Health recommends the use of an AIR, with negative pressure validated daily, but acknowledges that a single room—with the door closed—can also be used if necessary. The Public Health Agency of Canada advises that a patient with COVID-19 symptoms should be cared for in a single room with a private toilet and sink for designated patient use. The Agency recommends that infection prevention and control signage should be placed at the room entrance.

The Ability to Adapt

My teams and I try to design healthcare buildings that can be adapted. In a situation like we’re currently in, it’s important for hospital staff to be able to modify facets of their building to quickly respond. Resiliency is a key word here—hospitals need to be resilient, with the ability to pivot or change their functionality to respond to situations as they come up.

In the end, hospitals need to service the people of a community on good days and bad days, in typical situations and during worst-case scenarios. Hospitals must function for multiple uses and be able to react to a variety of circumstances.

I’m impressed with the way Canadian healthcare facilities have managed COVID-19 so far, and I’m intrigued to see how healthcare teams around the globe share best practices on preparedness as we face this pandemic and learn from one another.

Tim Eastwood is a principal in Stantec’s Toronto office, where he oversees the local healthcare sector. He focuses on every aspect of healthcare projects to advance the level of quality in design for the optimal staff and patient experience.

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SEATTLE—A study from the insurance company comparison website QuoteWizard of America’s hospital preparedness has uncovered a troubling statistic about the Golden State. California, the most populous state in the country, has only 1.82 hospital beds and 2.86 certified physicians per 1,000 people, ranking it as 11th-worst for hospital capacity in the entire country. The news comes at a difficult time, as physicians and medical practitioners continue to battle the coronavirus pandemic, with nearly 400,000 certified cases in the United States and 17,000 in California alone, according to CNN.

Auditors at QuoteWizard came up with their rankings by examining Kaiser Family Foundation data for each state’s bed capacity to handle the coronavirus pandemic. Based on their findings, West Virginia, New York and Pennsylvania ranked at the top in measures of preparedness, while Utah, Idaho and Nevada ranked at the bottom. Furthermore, their findings indicate that 23 states experienced a decline in hospital beds per 1,000 people from the period 2014 to 2018.

Social isolation is playing a promising part in the ongoing effort to “flatten the curve” of infections of covid-19, but access to adequate healthcare will be crucial for those who are already ill with the virus or require care for all other reasons that haven’t taken a break during the global pandemic. In addition to hospital bed capacity, the numbers of nurses, doctors and other healthcare professionals to adequately address the outbreak continues to be of concern, especially as those workers not only care for patients but also take care of their own health as the virus spreads in the healthcare community.

Nationwide, there is now an average of 2.96 physicians and 2.4 hospital beds for 1,000 people.

QuoteWizard’s experts reported that to come up with their composite scores for each state, they measured hospital beds and physicians’ overall preparedness. The firm, based in Seattle, also has offices in Denver and Sacramento.

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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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