The Pandemic-Ready Hospital: Initial Observations on Resiliency and Infection Control Strategies

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As we reach the four-year anniversary of the COVID-19 outbreak, we now have the opportunity to learn from new hospital facilities that incorporated innovative infection control and resiliency strategies before the pandemic. Design features, which were developed in anticipation of a COVID-like event, have been put to the test, and we can begin to assess how effective they have been in promoting patient and staff safety and operational flexibility.

While in most cases, rigorous controlled studies have not yet been undertaken, in conversations with clinicians, epidemiologists, environmental health and safety directors, and facility operators, some observations and preliminary conclusions begin to emerge.

The National Institute of Occupational Health and Safety recognizes that all employers have a responsibility to create a safe work environment. In Healthcare settings, elimination of hazards and engineering controls are more effective than administrative controls; PPE is the last line of defense.

Above all: Flexibility and Universal Design

Teams working on inpatient units with all-private, universal patient rooms were able to respond to the surge and the constantly changing needs of the patient population with more flexibility. More robust infrastructure in typical rooms allowed the team to flex up to ICU-level care as needed without moving the patient.

New Facilities Have Built-in Surge Capacity

In older, undersized facilities with more limited infrastructure, patient care was more likely to overflow into lobbies and other spaces not designed for patient care. Newer facilities, built to current standards and codes, were better prepared to absorb the surge in clinical areas, like surgical prep-and-recovery units, that were already properly equipped. Private ED treatment rooms should be designed to accommodate a second stretcher in a surge.

Limitations of Screening & Isolation

Because reliable testing was not immediately available and asymptomatic patients were found to be capable of transmitting the virus, much of the received wisdom about the value of isolation was quickly set aside in favor of assuming all patients and staff are potentially contagious. This leads to a greater emphasis on those strategies, like engineering controls, that make all environments as safe as possible for all occupants.

Filtration: Biggest Bang for the Buck

HEPA filtration proved extraordinarily effective in removing the virus from the air; incorporating HEPA filters into HVAC systems was a cost-effective approach to providing a safe environment for all patients and staff. The filters come with a significant energy penalty, so consider designing air handlers to accept a lower level of filtration in normal operating mode and HEPA filters when a threat has been identified.

Flexible Air Pressurization Enhances Staff Safety

The ability to adjust patient-room pressurization on a case-by-case basis became an extremely valuable tool for managing the crisis. Engineering controls that ensure air flows from the corridor into the patient room and not the reverse, created a demonstrably safer environment on the unit and supported confidence among the care team that their safety was being proactively addressed.

Illustration Credit: JB&B 

Patient room ventilation design allows facility operators and clinicians to change the pressurization of patient rooms as needed. By pulling more air out of the room than what is supplied, air will always flow from the corridor to the room.

Design for Enhanced Ventilation in Additional Areas

New facilities are already designed for high air-change rates—this, combined with HEPA filtration, created safe environments in most clinical areas. In Emergency Departments, consider applying the enhanced ventilation requirements of waiting spaces to the entire department. Additional ventilation in staff break rooms is an easy and inexpensive measure, as many staff transmissions could be traced back to lounges and pantries where team members congregate and eat.

100% Outside Air was Less Critical

At least in this crisis, the ability to introduce 100% outside air proved less valuable. Once it was shown that recirculated air with aggressive filtration and room pressurization could create a safe working environment, facility operators chose to avoid the energy penalties and challenges to humidification associated with outside air.

Technology Facilitated Care from Outside the Room

In the early days of the pandemic, when it was still unclear how the virus was transmitted, it was important to limit the time the nursing team spent in the patient room, and family members were not permitted to visit or stay with the patient. Patient room bedside technology played a critical role in keeping the patients connected with clinical staff and family members. With touchscreen tablets and digital foot walls, patients were able to communicate with family, adjust lighting and temperature, and remotely interact with clinical staff for meal orders and other assistance.

Our understanding of how facilities functioned during the pandemic is still coming into focus. If you have data you would like to share, or if you would like to collaborate on an assessment or study, please get in touch!

David Tepper, AIA                    John Koch, PE

Ennead Architects                   Jaros, Baum & Bolles