PW Health Designing our way forward v1.0

Designing our way forward

Not since WWII have we seen such an extraordinary level of disruption to everyday life. Moving forward in a post-pandemic world, our society will change and adapt in unprecedented ways. Our task as planners and designers is to work with our clients to define a “new normal”—to define a positive and resilient future state.

“One of the silver linings is that the COVID-19 pandemic has revealed an intrinsic global community interconnectedness. Ultimately, helping and being part of the solution matters most—whether you’re a designer or not.”

CAROLYN BAROSS, PERKINS AND WILL

Quoted in International Interior Design Association (IIDA), April 21, 2020

With human life expectancy increases come epidemiological transitions. We are experiencing changes in the types of diseases and illnesses we face as a collective society.

According to medical sociologists, the first transition was associated with the development of urban centers.

The increase in density led to viral diseases like measles and smallpox, while contaminated water contributed to communicable diseases such as cholera. Tuberculosis and respiratory diseases were even more serious problems, with social and cultural overlays related to harsh working conditions and overcrowding. The second transition, experienced by industrialized nations in the second half of the twentieth century, was the shift from acute infectious disease to chronic, noninfectious, degenerative diseases, their prevalence related to increases in longevity. Changes in healthcare delivery followed: prevention and lifestyle modifications, ambulatory care, and telehealth. Currently, U.S. healthcare is focused on active design strategies and healthy cities initiatives. The third epidemiological transition—the reemergence of infectious diseases with antibiotic resistance—was thought to be in some distant future. The result of the interaction of social and environmental changes resulting in the adaptation of the microbe, it was projected to be global in scope.

The question is: has it arrived?

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01 ― Infectious Disease Such as measles and smallpox.

02 ― Chronic Disease Such as cancer, diabetes, heart disease.

03 ― Resistant Infectious Disease Such as SARS, ZIKA, EBOLA, COVID-19.

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Take a deep breath. This is new territory for all of us.

How do health systems absorb the shock of a pandemic while maintaining routine services? How can they weather the pandemic phase and emerge stronger and more resilient to the inevitable next pandemic?

Transition Interim workplace options are established to address reasonable protection in the workplace and individual level of comfort around returning. Impact of work from home and telemedicine integrated in planning.

Both infectious and non-infectious patient Response

volumes require careful management.

Workplace restrictions follow government regulations to contain

Future Prep

the spread of the virus. Managing

Ongoing policies and

staff well-being and anticipating

protocols are adjusted to

patient surge are high priorities.

integrate new ways of working and optimize future resilience, health, and well-being.

Phases of the Pandemic ― Today’s focus is on the “Transition” phase Credit: WHO Pandemic Influenza Risk Management, WHO Guidance, 2017

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Charting the way forward: How we are partnering with clients to navigate this new paradigm Together, we are: Analyzing existing facilities and determining how they can be adapted to meet objectives for surge, social distancing, and future flexibility to meet the demands of a new normal.

Analyzing workflows to understand the nature of critical functions that must be brought back into operation in phases through short-term and longterm capital strategies.

Developing conceptual planning diagrams based on the analysis mentioned above.

Reviewing potential partnerships to extend institutional and campus resilience.

Analyzing the long-term impacts of telemedicine and “work from anywhere� practices on ambulatory, workplace, and medical education real estate assets.

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Managing surge.

At the onset of COVID, health systems quickly mobilized for surge capacity.

Some cities and states mandated capacity increases; in other areas, health systems ran surge simulations.

Most cancelled elective procedures in order to manage projected surge.

In some regions, projected surge did not materialize, leading to significant financial losses and disruption of routine service. In others, surge volumes were significant. Hospitals are now faced with how to productively repurpose alternate care sites.

What can this teach us about managing surge resiliently?

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Considering Alternate Care Sites

Assessment and Evaluation

Proactive Response Toolkits

With beds at a premium, cities

Undertaking a coordinated

To meet the needs of health

and health systems mobilized

assessment and rapid-planning

systems as they transition closer

quickly to convert a range of

process, we analyzed which

to normal in the flattened-curve

facilities beyond hospitals—

critical program components

period, we have prepared three

vacant schools, underutilized

needed to be present in

toolkits that offer strategies

or vacant former clinical

these facilities and which

that can be rapidly deployed

buildings, armories, convention

conventional components could

to manage a steady influx

centers—to serve the needs of

not be accommodated. We

of COVID patients over the

patients during this pandemic.

evaluated existing facilities to

next two years in a relaxed

Whether spaces were used for

repurpose for COVID overflow

regulatory environment:

quarantine or to administer

post-acute patient treatment

Low Acuity: Tools for alternate care

critical care, it was important to

and quarantine. These rapid

sites, aimed at healthcare facilities

quickly assess and identify the

assessments determined

that are trying to normalize operations

best facility options, including

usability for a range of functions

moving forward.

considerations for repurposing

(clinical and non-clinical),

Testing Sites: Tools for government

post surge.

maximum potential for the

health agencies as well as health

defined space, general overview of speed to market, and cost to convert.

providers that are deploying testing facilities in our cities.

Site Selection: An evolving tool that layers in different parameters to help our agency, institutional, and private partners in site selection.

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“Amidst the current outbreak of COVID-19, keeping patients, their families, and the healthcare workers at the front lines safe is a national priority, yet it is one that comes with unique challenges. When addressing this pandemic, hospital design and capacities are critical for success in both response and safety measures for all parties involved.

Our teams design with the priorities of emergency room spaces, rapid isolation and contaminant containment in mind, creating spaces that can be easily sectioned off to treat infected patients while keeping those outside safe.�

MARVINA WILLIAMS, PERKINS AND WILL

Navigating the course ahead.

Designing Differently:

10 considerations for the next normal.

This pandemic has shown us that there are both short-term and longterm actions that health systems can take to increase resilience to future pandemic events across their real estate assets. What these actions share is the goal of improving infection control to optimize the health and well-being of staff and patients.

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― 01 Health systems will deliver more convenient care, closer to patients’ homes.

― 02 Arrival sequences will be reorganized and refined to better manage infectious and non-infectious patients. Paths of travel originate when the patient leaves home.

Outpatient services Outpatient services will continue to move out of large acute hospitals or campuses in urban areas, while smaller

Arrival Process

community and rural hospitals will continue to consolidate

Electronic pre-registration will ease the arrival process, as

diagnostic outpatient on hospital campuses.

will the use of curbside check-in. Extensive use of “wait in

Urban Ambulatory Accommodations

car” policy until the health provider is ready for the patient.

New urban ambulatory accommodation can be located

Directional Signage

within small urban radii to serve communities without relying

Clear markings and graphics will minimize in-facility

heavily on public transportation. Public transportation will

destination seeking and help to maintain healthy distances

also improve service during public health emergencies,

between people. Exterior signage and campus directional

working to reduce peak demands.

graphics are flexible and can be modified for all entry points

Easy Access

during a surge event.

Facilities on ground floor locations (formerly retail space)

Designated Access

or in low rise buildings will allow easy in and out visits, with

Provide dedicated entrances to separate potentially

minimal internal waiting and elevator use.

infectious/contagious patients; identify fever center entrance

Telemedicine

and checkpoints or pop-up testing sites. Provide directional

Telemedical consultations can provide convenient, direct

signage to tent triage or other ED related temporary

care. Visit volume implications of telemedicine can and

facilities.

will reduce total square footage required to treat a given

Access to Power and Data

number of patients.

Additional power and data are provided at screening areas

Monitoring

at entrances (staff, public, ED, etc.) inside and outside, to

Expansion of passive home monitoring of chronic, infectious

manage surge.

and at-risk patients can prevent adverse events that would

Common Spaces

otherwise require a visit to a hospital. 80% of COVID-19 cases

Common spaces such as public lobby or education spaces on

are being managed at home.

the ground floor will be equipped to handle high surge demand, including concealed med gas panels in these areas and incorporating variable air flow responses.

Temporary Shielding Reception desks will be outfitted with temporary shielding/ biological barriers.

Sanitizing Precautions Convenient and multiple hand sanitizing and face mask dispensers will be provided at all entry points.

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― 03 Touchpoints will be managed differently.

― 04 New partnerships between hospitals, hospitality, and retail will create more mixed use “health” campuses capable of accommodating a range of staff and patient needs during pandemics.

Cleaning Practices Refer to USEPA and CDC published recommendations for cleaning practices.

Product Authentication Be wary of materials and products with “antibacterial”

Repurposing Facilities

properties; many claims are unsubstantiated.

Repurpose campus medical office buildings for surge use.

Disinfectants

“Control Center”

Fixed and robotic UV light sources for disinfection can augment manual cleaning.

A main “Control Center” will manage day to day real time

Fixed UV sources can be added to existing duct work.

bed disposition, other campus “temporary beds”, sub-acute

data viewed across the system for surge planning, inpatient

Mobile units can be deployed to assist in sanitizing

bed management, ambulatory activity, and home care.

and disinfecting exam rooms, patient rooms, and

Onsite Hospitality

procedure spaces.

Conveniently located hospitality enterprises will

Contactless Operations

accommodate both staff and patient needs during

Touchpoints for registration can be moved to phone apps

pandemics, housing staff that require extended stay or

and away from hospital tablets.

for sub-acute patients required extended quarantine or observation. On-site hospitality may also incorporate

Door hardware and plumbing fixtures can be switched to

conference centers that can be repurposed during

contactless operation.

surge events.

Privacy Systems

Non-healthcare Partnerships

Cubicle and patient room privacy curtains can be exchanged

Retail partnerships will respond to increased flexibility

for instant-on, instant-off systems that are disposable and

and choice for food/meals, health related retail and

recycled by the vendor.

wellness products, exercise, and positive distraction for family and staff.

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― 05 Emergency departments will be more likely to perform the role for which they are intended when prospective patients feel safe coming to them during and following surge events.

― 06 Inpatient environments will manage known and undiagnosed infections and be able to accommodate both surge and flex of ICU and total bed capacity.

Room Occupancy Remaining double-bedded rooms will be reevaluated for

Waiting Areas Arrival will be reconsidered to immediately separate

single bed use.

potentially infectious and non-infectious patients, with

Mechanical Systems Evaluation

separate entrances, triage and negatively pressured waiting

In existing hospitals, HVAC systems will be reevaluated for

areas that access separately ventilated treatment areas.

the ability to deliver more negative pressure rooms per

Triage Coordination

nursing unit.

Emergency Department intake and triage processes will be

Regulatory Compliances

redesigned for more efficient through-put; patients can

In existing facilities, nursing units can be designated, with

notify the ED when they are en-route and be directed to the

state regulatory concurrence, as convertible for ICU patients

appropriate location/entrance.

if certain basic air flow, life safety, and equipment space can

Power and Storage

be addressed.

Provide electrical/plumbing connections for mass casualty

In some cases, existing buildings that do not meet current

holding refrigerator/trailer unit (in parking lots) with

ICU or recommended negative pressure sufficiency can

electrical tie ins on emergency power. Provide extra storage

be modified externally, significantly reducing the cost of

for tents/equipment.

creating surge and flex capacity.

Temporary Decontamination Areas

Increasing ICU Capacity

Additional power/data and infrastructure for screening

New hospital patient rooms will be designed to

areas at ED entrances and immediately outside to

simultaneously meet all basic acute and all ICU

accommodate temporary tent decontamination, triage, or

requirements, so that ICU capacity can be increased without

holding areas during surges.

architectural changes.

Isolation Protocols

Isolation Rooms

Negative pressure and individual isolation protocol exam

New hospitals will incorporate the ability to operate

and treatment rooms will be replaced by separate systems

complete Isolation floors in addition to having two isolation

for clusters of exam rooms capable of handling infectious or

rooms typical to all nursing units.

non-infectious patients.

Personal Protective Equipment (PPE) Storage

Dedicated ED Systems

PPE cabinets will be installed in front of all patient rooms.

Dedicated power and ventilation systems for EDs will allow

Managing Surge Capacity

them to remain operational, even if the balance of the

Total bed capacity will be increased through temporary

hospital is evacuated or inoperable.

partnerships with nearby hospitality, convention

Visitor Communication

centers, regional surge facilities, or temporary tent

Televisual systems will support communication between ED

structures on campus.

patients/staff with family members rather than visitors directly accompanying patients during surges.

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― 07 Inpatient staff and patient flow to major diagnostics and surgery will manage both infectious and non-infectious patients discretely.

― 08 More inpatient and outpatient clinical environments will incorporate negative pressure heating, cooling, and ventilation.

Exam Rooms New outpatient facilities can be designed for negative

On-stage/Off-stage Flows

pressure exam rooms, either in full or as a major proportion

On-stage/off-stage flows will reduce possible contamination of food/supplies within nursing units.

of exam spaces.

Managing Infection Flow

Building Exhaust Building exhausts can be extracted from negative pressure

Elevators can be designated for infectious/noninfectious patient and staff movement between floors. Movement of

spaces.

known-infectious inpatients may be made safer using

Vertical Circulation

portable isolation chambers and high velocity negative

Elevators and/or elevator shafts can be retrofitted for

pressure elevators.

negative pressure.

Dedicated Paths of Travel

Mechanical Systems

Dedicated paths of travel or distributed diagnostics will

Existing HVAC systems can be evaluated for the ability to add

provide discrete flow for infectious patients requiring

negative pressure in a range of patient environments.

diagnostics. Diagnostic areas will include increased numbers

HVAC filters will be treated as contaminated waste and use

of negative pressure rooms.

appropriate protocols.

Managing Surgery Flow

Toilets and Washrooms

Patient flow to Surgery will accommodate infectious patients

Toilet facilities should be evaluated for increased ventilation

from arrival/pre-op through PACU. PACU design will

to prevent transmission via aerosols produced with each

incorporate cluster design to provide the ability to designate

toilet flush.

portions for infectious patients.

Portable Mechanical Systems Portable air handling units can be used to augment air in existing facilities, requiring a room or external location.

“Plug-and-Play” Every patient room and ED treatment room will be designed to allow “plug-and-play” modular AHU modifiers that easily convert the rooms into negative pressure airborne isolation rooms.

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― 09 Outpatient throughput and waiting will be challenged by social distancing for staff and patients; providers will utilize a range of strategies to maintain consistent volumes.

― 10 Health systems will better attend to staff needs during and following surge events.

Patient Throughput

PPE storage, gowning, and doffing areas will need to be

Waiting will be minimized through a series of activity timing,

incorporated at departmental entrances.

visitor restrictions and patient throughput recalculations.

Staff Accommodations

Isolated Exam Rooms

Incorporate housing options for staff worried about exposing

Waiting will have designated, negative pressure, discreet

their families or otherwise needing extended stay on

area for infectious patients, with direct access to isolation

campus. This may be accomplished through partnerships

exam rooms.

(04) or through transforming hospital spaces. For example,

Personal Protective Equipment (PPE) Secure adequate PPE for staff use.

large conference rooms can be converted into on-call rooms

Waiting Areas

with temporary walls, added electrical/data and more

Waiting space will have furniture distanced in accordance

permanent restrooms with showers close to the specified

with CDC social distancing guidelines or be equipped with

area.

signage indicating that social distancing should be

Staff Wellbeing Support

maintained in seating choices.

Expand the range of free, on-demand emotional support

Physical (clear) barriers or sub-waiting spaces will also

services, such as meditation sessions or tools for coping with

enhance safety and increase seating counts.

anxiety.

Screening

Physical Distancing

Outpatient settings will include provisions for screening and

Design staff lounge spaces with sub-areas and zones that

testing upon entry. Where possible, exit from outpatient

allow observation of physical distancing off-stage.

settings will allow for discreet exiting for both infectious and

Staff administrative areas will need to accommodate social

non-infectious patients separate from waiting.

distancing, and this may increase reliance on televisual

Physical Distancing

consultations within and between departments. Work from

Staff areas will also require appropriate social distancing

home policies may decrease the number of administrative

spacing, and this will increase reliance on televisual

workers on site at any given time.

consultations within and between departments or specialist

Staff Amenities

caregivers.

In new hospitals, incorporate dedicated outdoor spaces for staff on nursing units.

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Working with our clients We believe that flexibility and resilience are key to innovative solutions. These built projects have incorporated features that address pandemics past and present and point to the importance of flexible long-term planning solutions that are resilient.

→ At Lucile Packard Children's Hospital Stanford, people are screened at reception; potentially infectious patients are moved to negative pressure triage and can be escorted either to beds or exit the building discretely. In a pediatric pandemic, a portable screening tent can be erected in the adjacent garden.

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Rush University Medical Center, completed in 2012, includes universal rooms with ICU capability, including HVAC systems that support individual floor conversion. They were able to rapidly increase ICU beds at minimal capital outlay.

→ University of Virginia Medical Center University Hospital Expansion incorporated tent triage flexibility adjacent to the emergency department and added three high-velocity stack fans on the roof to provide additional patient rooms negative air pressure.

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What challenges do health systems face during a pandemic?

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The business bottom line

Staff safety and equipment

Diagnosis and prevention

Revenue loss from cancelled

Front-line care providers are

Despite the immediate need

elective procedures immediately

celebrated and highly valued,

to identify potential infections

upends the business model

but adequately protecting

among staff, patients and

of community hospitals and

staff with appropriate PPE and

visitors, testing delays and

urban academic medical

providing adequate extended

shortages make widespread

centers alike; some experience

stay accommodations remains

diagnoses a challenge. As

a surge in patient census while

a challenge. The pandemic

hospitals resume elective

others become vacant almost

heightens a shortage of ICU

procedures, many are

overnight. Already cash-

specialists and respiratory

integrating COVID testing into

strapped rural hospitals face a

therapists, and the demand

pre-surgical testing protocols.

25% chance of imminent closure

for critical care beds and

Meanwhile, the potential for a

as a result of the pandemic,

life-sustaining ventilators

second wave of the pandemic

potentially eliminating essential

exceeds supply in many regions.

prior to the availability of

access for thousands of

Weaknesses in the supply chain

a mass-produced vaccine

patients.1 Likewise, heightened

has challenged “just-in-time”

looms large. Hospitals are

public fear of viral exposure can

deliveries and is leading to new

reconfiguring triage and intake

lead to an avoidance of early

requirements for PPE stocks.

processes, as well as patient

treatment for chronic illnesses

flows, to address the expected

and increase patient acuity

second wave of patients

when treatment is eventually

without the disruptions that

critical, further stressing bed

were experienced the first time.

capacity and care capabilities.

David Mosley and Daniel DeBehnke, MD, “New Analysis Shows Worsening Situation for Rural Hospitals, Residents,” February 2019,

1

https://guidehouse.com/-/media/www/site/insights/healthcare/2019/ navigant-rural-hospital-analysis-22019.pdf

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Hopeful outcomes for the future

― 01

― 02

Future pandemic cases create less disruption to normal health system operations

Intake, diagnosis, treatment and postacute care processes are streamlined

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― 03

― 04

― 05

Adequate accommodations are available for staff who spend increased time at the hospital

Reduction in staff contamination

Improvement in patient outcomes, decreased fatalities, and improved community health

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For more information contact: health@perkinswill.com