Hospitals After COVID-19: How Do We Design For An Uncertain Future?

In many places, the immediate response to this crisis was to provide surge capacity by converting large buildings such as stadiums or conference centres, or by constructing entirely new field hospitals from scratch. For the future, this strategy is shifting to provide extra capacity within hospitals themselves, or in very close proximity, so that they can more easily access the staff, equipment and infrastructure they need.

This time, the switch to “pandemic mode” has involved reconfiguring hospital entrances and layouts to separate infected and non-infected patients and associated flows of staff, equipment and consumables. Intensive care units (ICUs) were scaled up to care for a surge in critically ill patients, and isolation rooms improvised by installing fans and filters to create negative pressure. For the next time, greater flexibility in both spaces and systems can make the transition smoother and more effective. ICU rooms, for example, need a higher level of emergency power redundancy and a medical gas supply for patients on ventilators, and the hospital infrastructure has to be able to supply a much higher demand for oxygen.

“Converting normal patient rooms to ICU rooms is not plug-and-play,” says Gary Hamilton, healthcare practice leader at WSP, based in Washington DC. “You can’t just plug in all the equipment that’s required to keep the patient alive because the requirements are very different.” On one conversion project, he found that the medical gas system could be stretched a little – but that the hospital pipework wasn’t big enough to carry the higher loads. “We could have increased that during the design with a marginal effect on the whole infrastructure cost, and we wouldn’t have had a problem. But we weren’t designing for a pandemic. This is unprecedented, but it’s teaching us that instead of designing to the minimum the code allows, it’s important to take a flexible approach.” Other relatively minor design changes include installing an extra set of entry doors and extra fire doors between departments, to aid separation and compartmentalisation.

But exactly how far should we go? How much should owners and design teams try to anticipate the future, and what level of flexibility is it worth paying for today? Engineers already consider the interplay of emergencies from natural disasters to mass shootings, and the pandemic adds another layer on top. Raising code minimum could make the process easier, says April Woods, a vice president with WSP in Florida. She thinks the impact of COVID will be comparable to that of Hurricane Andrew, which devastated the state in 1992. “That changed a lot of the building codes here and up the coast, for all buildings and also very specifically the resilience of healthcare facilities. In the coming years, I think greater flexibility will just become a standard of care that we have to implement in all of our designs – for example, to allow the engineering systems to be quickly changed to accommodate a pandemic. When those become code-required elements, owners don’t have to decide whether to opt into something or not.”

Further into the future, advances in such diverse fields as telemedicine, wearables, genetics and artificial intelligence will mean hospitals need to accommodate new equipment for diagnostic testing and treatments, while shortening stays or making them unnecessary for all but the sickest patients. “Now hospitals are designed around the need for longer stays in high-acuity settings like ICU and med/surg,” says Nolan Rome, leader of WSP’s US healthcare practice. “But the baby boomers are going to be the next acute care generation, and we’ve never seen a patient population that has lived healthfully this long before. We don’t know what treatments they will need. Maybe those ICUs will be downgraded in acuity to become transition beds or short-term surg beds – or even exam bays because there is more day surgery.”

In a hospital context, it is neither desirable nor economical to equip spaces for any possible future use, especially given the increasing sophistication of medical equipment. Instead, we need to consider specific adaptation scenarios upfront and design for these. “We need to be very specific about the limitations of an area and exactly what it will be able to adapt to,” says Gunnar Linder, business area manager at WSP in Sweden and a specialist in engineering healthcare environments. In Gothenburg, WSP designed a highly specialist imaging facility with a modular, demountable facade. All of the operating theatres are located around the perimeter so that one side of each room can be completely opened up to replace the bulky equipment inside. The building systems can also be sealed off, says Linder, “so you can have a construction site within a fully operational ward”.

In the light of COVID, and our heightened awareness of uncertainty, decisions that would have seemed counter-intuitive may become no-brainers. “We need to take more of a life-cycle analysis approach to resiliency decisions,” says Rome. “If a resiliency measure costs an extra 10%, does that 10% investment add value over the 50-year life cycle of the building?”

Healthcare owners rarely, if ever, sell their assets, Rome says, so they are in a good position to take a longer-term view. The US is a very competitive, cost-driven healthcare market, but providers are incentivized by government and insurance companies to reduce both length of stay and repeat visits. This has given them an added impetus to go beyond code minimum: “Most owners will do something if it’s a six-year payback or less. Anything in the seven-to-ten-year range, they will heavily consider if it helps to mitigate their risk, whether that’s infection risk or business case risk.”