Assessing interventions in the post-pandemic era

Isolation rooms with anterooms at Memorial Hermann – Texas Medical Center’s Susan & Fayez Sarofim Pavilion in Houston.

Image © Robert Benson Photography

Health care providers operate in a highly regulated environment but are also required to maintain rapid adaptability in the face of changing patient needs. The COVID-19 pandemic highlighted the need for long-term planning and adaptability beyond the range of normalcy.

Despite these contradictory challenges, operators continue to innovate care, expand influence and maintain modest margins. Facilities, though cost centers, are essential for revenue generation, and evolving design considerations are crucial to meet unknown future needs.

During the fog of the pandemic, various groups provided urgent guidance on pandemic response and surge preparedness, emphasizing national security implications. However, these recommendations, along with rising construction costs, have significantly impacted health care project budgets.

Federal Reserve Economic Data tracked health care construction cost increases of 34% from 2021 to 2023, which have remained at that plateau throughout 2024 and owner requests have added another 16%. This forces the field to continuously reassess project priorities to align with financial constraints.

Following are several common reactive recommendations and how they’ve aged since the beginning of the pandemic.

Operational and financial

While many of these concepts are not new, it is prudent to discuss them operationally and financially because current programming questions are very different than they were just a few years ago. These concepts include:

From left: Hackensack Meridian Health Hackensack (N.J.) University Medical Center’s Helena Theurer Pavilion features a universal bed chassis for surge flexibility, and UCHealth University of Colorado Hospital’s Anschutz Inpatient Pavilion 3 in Aurora has isolation and surge capabilities.

Left Image © Jonathan Hillyer and right image © Caleb Tkach

Double-occupant patient care rooms. While current codes have mandated single-occupant inpatient rooms, emergent surges require reallocation of every resource — including space capacity by considering doubling up patient room occupancies. Beyond the suboptimization of the patient experience and unwinding of research that illustrates changed infection rates, there are several other factors to consider.

Many contemporary patient rooms allow space for family members. It is possible to use that space to accommodate two patients within the same room, if required. This strategy, typically seen in emergency trauma rooms during mass-
casualty incidents, may be appropriate for consideration in inpatient settings. Many hospitals choose to provide a higher number of headwall outlet devices to allow for higher acuity needs, which also could be used to double-up patients if required and permitted by authorities having jurisdiction under special circumstances.

It is not just the room devices. The zone panels and distribution infrastructure also must increase — sometimes upstream to the generation point (e.g., an oxygen farm has increased capacity and pressure). Acuity adaptation and double-capacity-capable rooms need to be sized accordingly beyond code minimums.

Public space conversion. Not all space is equal. The patient safety risks of inpatient areas, especially critical care environments, are different than those for lobbies, dining areas or conference rooms, and astute designers of the support systems will discount the latter to reduce overall infrastructure costs.

Permanent medical gas piping and outlet installation in public spaces carry a substantial first cost premium per outlet as well as increased operational and maintenance costs for the life of the facility, and many question their value. Also, public spaces are still necessary for a surge and their utility demand will increase as the skilled clinical staff demand cascades to all support services.

Some designers and clinicians postulate that cohorting patients may be safer for all, and it’s better to consider designing surge capacity into inpatient units rather than the suboptimized disruption of public spaces for inpatient care. Testing and vaccination clinics may be perfectly suitable repurposes for public spaces.

Dedicated access points and temporary on-site locations. As hospitals must manage populations entering and exiting, it may be helpful to dedicate access points based on needs.

However, sometimes those plans fail when patients who enter a campus in a stress-induced state of confusion select incorrect entrances. Furthermore, in many cases, patients may be unsure if they truly have a communicable condition and are unaware of which hospital entrance they should use.

While the design for a normal state is reasonable, designing for a surge state is necessary. Designers are advised to model various scenarios, including off-site instructions related to limited entry points and various visitor management policies. They should be consistent with these points of entry and exit, as changes increase agitation.

Also, because there are more staff, patients and visitors, all building occupants may be more stressed, which requires different and increased security protocols. Depending on the conditions of the surge, triage may be required at every entry vestibule, not for preliminary diagnosis but to confirm the basic health parameters of building entrants.

Local communities participate in annual joint catastrophic event drills, where they employ non-hospital infrastructure in their planning for such events. Additionally, tents or other temporary structures can be employed on a mass-casualty site, a non-hospital site or a hospital campus for testing and clinical vaccinations.

Often, a state or regional agency, rather than each hospital or system, will lead a concerted effort because the issues are not only physical but include managing non-resident care providers and supplies.

Crisis command centers. Early in the pandemic, there was confusion about the adequacy of crisis command centers and communication control rooms for daily administration. The crisis command center took several forms but captured considerably more space than a communication control room.

The hospital command center at Nemours Orlando (Fla.) Children’s Hospital.

Image © Jonathan Hillyer

While larger hospitals used this for daily operations, smaller facilities may have had several attempts at transforming multi-functional space. In other forms of surge (e.g., weather-related events), the activation of the crisis command center is based on the intensity, duration and clinical needs required by the risks.

Designers are advised to identify conveniently accessible conference rooms and equip them with the required infrastructure (especially information technology) to be able to engage and coordinate with the appropriate local, state or federal agencies.

Flexibility through vacant space or an “open chair.” Every facilities manager wants the flexibility associated with a vacant unit to meet anticipated surges. However, the cost of maintaining them during normal operations and overbuilding to accommodate surges may become prohibitive.

“How much is enough?” always results in an imperfect answer, as the pandemic overwhelmed hospitals in some parts of the U.S. while others operated normally. Care and facility scenarios must be planned ahead of time to understand future demand conditions. And while acuity-adaptable rooms are more expensive to plan and adjust later, they are hardly the solution during an immediate crisis.

Dialing in the perfectly balanced facility scenario means nothing if staff and supplies are not available. If an open chair is commissioned, the normal balance of elevator access and heating, ventilating and air-conditioning controls also will need adjusting.

Designers should consider planning a universal chassis for the bed tower and allow the medical-surgical rooms to be upgraded in the future, if required. This may better support a surge but, depending on the long-term acuity trends of a market, also may facilitate adaptation from medical-surgical beds to step-down or critical care units. Doing so will require additional infrastructure that won’t be immediately employed.

A flexible design allows for double occupancy within the trauma room at Memorial Hermann – Texas Medical Center’s Susan & Fayez Sarofim Pavilion.

Image © Robert Benson Photography

System-level adjustments. While many independent hospitals continue to operate very well, many more have been brought under the umbrella of a health system. Systems have unique advantages related to surge capacity by dedicating a surge hospital in a city or region, allowing other hospital operators to transfer or direct patients to the dedicated location based on a diagnosis, like a specialty referral hospital.

This allows the other hospitals to maintain normal operations or accept the transfer of higher-revenue procedures free of the surge condition. Climatic or societal changes may develop at a slower pace but represent the same issues as an acute surge event. Systems also allow non-clinical staff and system infrastructure to be collocated as necessary at lower operating costs.

Equipment, supplies and logistics. The pandemic introduced the world to specialized terms such as personal protective equipment, donning and doffing, and others. It also highlighted threats to health and national security through expired or undersupplied stock of medical supplies.

While a framework for a national solution exists, consistently managing that framework outside of a crisis is challenging. As was discovered during the pandemic, many of the supplies are manufactured or have ingredients that are manufactured in regions that are subject to geopolitical pressures well beyond the supply chain. Systems must wrestle with balancing normal supply par levels with the potential of a short- or long-term crisis. During the pandemic, just-in-time systems collapsed.

In a prolonged surge, the potential for waste increases. Laundry and food services also are subject to similar pressures. Some systems are developing consolidated service centers to better control systemwide inventory and distribution of consumable products.

Other concerns. Several other issues require discussion when planning for a prolonged surge event. Some of these relate to resilience against weather events of increasing intensity, where roofs may be designed for 135-mph uplift, infrastructure or ground floors are above the 1% likelihood of an annual flood plain, trees are not planted near roadways or buildings, and the exterior envelope systems are hardened, among other measures.

Also, many health care systems have acknowledged or embraced sustainable practices by committing to sustainability goals, considering energy banking systems via geothermal fields and installing triple-pane glazing, high-performance envelopes, solar arrays or other on-site power generation strategies. With the life expectancy of a new facility being less than 75 years, the risk of a centennial event must be carefully evaluated.

Opinions from the field

The concepts discussed here were shared with health care facility designers at a recent gathering to learn about their diverse real-world perspectives. The designers were asked:

• How might the future of technology, artificial or augmented intelligence, hospital-at-home strategies or other trends affect a health care system’s ability to support care?
• With the combination of additional considerations and sustained cost escalation, how might designers advise senior executives?

Many agreed that federal policy and reimbursement drive the health care enterprise. Some expressed intrigue but unfamiliarity about inpatient care in a home setting and what unknown infrastructure may be required to support it systemically.

The input varied considerably, suggesting that the design professions have no single collection of priorities or approaches to developing these discussions. There appeared to be consensus related to the following issues:

• Not over-designing as a reaction to the pandemic.
• The realities of cost escalation.
• The constant demand for rapidly adaptable environments.
• The ongoing difficulties of getting C-suite leaders to understand the realities of design and construction.

Others were less conclusive regarding not designing to bare minimums to balance first cost against future adaption; the expense of installing medical gases in public spaces to cater to surge demands; not designing for centennial events because some of the buildings won’t last that long; and that capacity is not defined by beds alone but also by medical staff, supplies and other collateral systems.

The planning and design approaches that many have taken in the recent past have been altered, at least for the foreseeable future, by the effects of the pandemic. However, this influence may be reduced over time. Prudent design and planning leadership require architects to consider the realities of the recent past and insist that they be considerations for the future.

Reasonable solutions

Designers must be thoughtful when planning health care facilities and prepare for the unknown future while ensuring that they consider the ever-increasing cost of health care construction.

Thus, it may be prudent to incorporate reasonable design solutions that enhance flexibility and adaptability, elevate patient care capacity and allow clinical teams to provide the required care during regular as well as surge conditions.

Related article // Specialized patient care rooms

The patient room has been the traditional anchor place for inpatient care. During the pandemic, and across other surges, these spaces tended to morph based on immediate needs. However, special care rooms have additional requirements that cannot be compromised. They include:

• Isolation rooms in hospitals. Isolation rooms are special hospital rooms that may be needed for patients who may be infectious and need to be separated to prevent the spread of pathogens or communicable diseases. Isolation rooms also may be required for patients who have a condition that makes them more easily infected by others. The ANSI/ASHRAE/ASHE 170, Ventilation of Health Care Facilities, and the Centers for Disease Control and Prevention govern heating, ventilating and air-conditioning systems in health care facilities and provide guidance on the design of these rooms.

• Airborne infection isolation (AII) rooms. While all private patient rooms allow for contact isolation, only AII rooms are appropriate to separate patients with infectious diseases. They maintain a 2.5 (pascal) Pa negative pressure relative to adjacent areas, provide 12 air changes per hour and exhaust air directly to outdoors or pass through a HEPA filter that removes 99.97% of droplet nuclei.

  During the pandemic, several hospitals created temporary negative pressure rooms by adding HEPA-filtered negative air machines that either exhausted air directly to the outside of the building, connected to the return air grill within the patient room or created a sealed vestibule outside the patient room. While these approaches are effective in creating negative pressurization, it is imperative to ensure that the room ventilation still meets the designed ventilation requirements, such as air changes per hour, humidity and temperature.

• Positive isolation rooms. Separately, positively pressurized isolation rooms, also called protective environment (PE) rooms, may be required to protect high-risk immunocompromised patients from human and airborne pathogens. These rooms must maintain a 2.5 Pa positive pressure relative to adjacent areas, provide 12 air changes per hour and be supplied with HEPA-filtered air.
• Combination AII/PE isolation rooms. Isolation rooms switchable between negative and positive isolation are no longer allowed. To address the need to protect an immunocompromised patient with a known infectious disease, Standard 170 includes guidelines for a combination AII/PE room. Unlike separate AII and PE isolation rooms, the combination isolation room must be used with an anteroom. The pressure relationship for the anteroom shall either be positively pressured related to the AII/PE room and corridor, or negative in relationship to the AII/PE room and corridor. The exhaust from the combination AII/PE room, associated anteroom and associated toilet room must be discharged directly to the outdoors without mixing with exhaust from any non-AII rooms. 

About this article

This feature is one of a series of articles published by Health Facilities Management in partnership with the American College of Healthcare Architects.

Bill Hercules, FAIA, FACHA, FACHE, is CEO of WJH Health in Orlando, Fla., and Akshay Sangolli, AIA, ACHA, EDAC, LEED AP BD+C, is principal and lead health care planner at Page in Denver. They can be reached at bill@wjh-health.com and asangolli@pagethink.com.