The purpose of this paper is to identify and posit solutions for critical issues related to the care environments being considered by policymakers as the COVID-19 crisis continues to affect more citizens of the world, and what specific considerations relate to this architecture. History instructs – and, more specifically, Florence Nightingale demonstrated – that the built environment had more of an effect on wounded soldiers than their initial wounds.¹ We argue that the built environment is a critical part of pandemic solutions and emergency preparedness.

Policymakers may believe that any enclosed space will suffice, but this is a simplistic view that space is space, patient rooms are patient rooms, and widgets are widgets. This is not the case. While policymakers are wired for action and solutions, many lack the necessary information and access to the proper advice. In fact, all of us are operating in a clumsy improvisational dance as we race against the calendar. Improper environments of care may create many unintended consequences.

Architects, in general, and specifically board-certified healthcare architects² and certified health facility engineers,³ are key and valuable resources for rapid adjustments to current hospital and non-hospital infrastructure – repurposing old healthcare buildings, erecting temporary structures, and considering emergency preparedness in our building’s codes and design guidelines.⁴ Current space utilisation in hospitals can be quickly evaluated by these experts to maximise existing areas for use.

With the rapid worldwide spread of the SARS-CoV2 virus and the resulting COVID-19 disease, leveraging all forms of professional expertise and specialties is paramount to a rapid resolution of the crisis, avoiding unintended consequences in the short term, and embedding resilience in our health systems in the longer term. Given we have no current vaccine or effective treatment available, we must turn to non-pharmacologic means – including social distancing, isolation, and quarantine – all of which depend upon the built environment. Our homes, neighbourhoods, healthcare settings, infrastructure and cities play a central role in emergency preparedness and response.  Harvard’s Global Health Institute underscored the urgency based on current bed demand across the US in several scenarios, concluding that “vast communities in America are not prepared to take care of the COVID-19 patients”.^5,6

Space, as it relates to infectious disease epidemics “isn’t just about quarantine; it’s also a design problem”, according to a recent article on Curbed.⁷ In the face of airborne pathogens communicating to humans so freely, “. . . the only thing we have left is quarantine”,⁸ argues critic Geoff Manaugh, who is writing a book on the subject. At least temporarily, he suggests: “We have to return to this kind of medieval spatial response to disease control, which means that architecture and urban design suddenly become medical.”⁹

Specific qualities of space enclosures for COVID-19                                                                     

While the American Society for Healthcare Engineering (ASHE)¹⁰ and others¹¹ have clarified the health facility-related recommendations from the Centers for Disease Control and Prevention (CDC),¹² the devil is in the details to affect the range of patient conditions. And these environments of care do matter. Architects are ready and positioned to emphasise the impact that the built space has on health outcomes and how care is delivered.

If patients require hospitalisation according to emerging treatment modalities, they will need either a room with negative air pressure with respect to other nearby spaces, or increased isolation provided by an airborne-infection isolation room (AIIR), similar to the rooms used to resist tuberculosis. Both have specific air filtration and exhausting requirements to protect the patient within its enclosure, the caregivers, and others in adjacent spaces. However, typical hospitals will have a small number of these types of rooms, and some may have none.

Existing hospital rooms may be modified to accommodate these specific air pressure requirements, and the ASHE and others have documented some of these approaches.^13,14 However, they will require rapid and concentrated physical and operational adjustments. Additionally, before each room is available to accept patients, the air balance must be tested and confirmed in order to manage contamination risks, which are numerous.

Scenarios for housing COVID-19 patients                                                                                        

Our number of acute- and intensive-care beds will be exhausted quickly by this coming tsunami of COVID-19 patients.¹⁵ There are at least three types of environments of care that have various degrees of suitability to house this influx of patients: current hospitals; homes, nursing homes, and hotels; and quickly constructed alternative locations, such as vacant spaces in office buildings, prisons, tents in vacant parking lots, etc. Each have their specific challenges from a life-safety and building services standpoint. Evaluating them will require careful triage by qualified professionals, including architects and engineers, and rationing of available caregivers, therapies, environments, equipment, etc, which may evolve fluidly.

Existing hospitals are the best location for patients who need focused medical treatment for COVID-19 and have other medical co-morbidities. Additionally, some of these conditions will trigger critical care, involving co-location of highly specialised teams with specialised equipment. These systems may or may not be quickly adaptable, despite actual spatial capacity. Infrastructure adjustments will also include building support systems, such as HVAC and power capacities, technology, etc. These are the most regulated of the environments of care and, while modifications may be allowable, care should be taken to engage a credentialed healthcare architect so as not to adversely affect other ongoing hospital operations.

Homes, nursing homes, and hotels may become alternative places for less-critical patients to be treated. However, such approaches are caregiver-intensive and inefficient. These places do not have caregiver deployment systems and the qualities of the care environments are diverse and unlikely to meet reliability standards for consistent outcomes. Specialised equipment, such as ventilators and ECMO machines, are very unlikely to be available in this context. Personal protective equipment (PPE) must be managed, along with a strategy for monitoring it and managing associated equipment. While these alternative spaces may be readily available, the supporting systems must be invented in real-time. Adequate and patient-appropriate life safety, HVAC, normal electrical power (and perhaps emergency power), secure communications and data systems must be considered at each location.

If a home or a room in a nursing home is employed for acute care, a temporary high-efficiency particulate air (HEPA) filtration machine will likely be required to cleanse the air surrounding a patient’s bed. These machines have specific power requirements, require “make-up air”, and are loud. Additionally, the bedroom door must remain closed, the existing air-return grilles closed and sealed, and the entry used by caregivers in protective gowns should be sealed. These pressure differences will create difficulties with the rest of the HVAC system, and the bedroom door may be difficult to open or close if sealed.

Hotel rooms must be similarly equipped with HEPA filter machines and sealed. Life-safety systems must be capable of supporting patients who may not be able to evacuate the building on their own in an emergency. We recommend that a floor, or zone of a floor, be designated for this use, as that floor or zone will be considered contaminated and cordoned off from the rest of the building, limiting elevator (lift) access to caregivers only. The HVAC system affecting this zone will likely need to be rebalanced. Patients with respiratory ailments generally require oxygen. While these can be supplied in portable tanks, concentrating a collection of portable oxygen tanks represents a potentially explosive fire risk, beyond the construction type of normal hotels.

Hotels also have different geometries than hospital inpatient units. Hospital corridors are eight feet wide to facilitate beds passing and rotating a gurney to enter a patient room. Hotel corridors are five or six feet wide and have narrower doors. While housing patients is one thing, having adequate space to support active nursing is another. A typical modern inpatient unit in a hospital requires about 1.5 times the additional space to support staff, supplies and equipment. This means that some hotel rooms will need to be converted for nursing stations, equipment storage, clean supply, soiled utility rooms, etc. A hotel with 24 rooms on a floor may be able to support only 10 to 12 patients.

Alternative places beyond traditional medical infrastructure must be approached carefully. Time is the enemy, and we simply can’t pivot rapidly enough for a traditional building with special considerations; nor will policymakers have the patience for such.

Temporary construction must still meet life-safety requirements for patients who are incapable of self-preservation in a building emergency. Tent hospitals may be set up in parking lots, but they must also provide proper and protective air circulation for patients and caregivers, and emergency egress.

Office buildings may become available as temporary patient enclosures, but their construction is typically not conducive to patient-appropriate life-safety, limiting the number of patients who could be housed in such places. Adequate and patient-appropriate life safety, HVAC, normal electrical power (and perhaps emergency power), secure communications and data systems, will need to supplement the existing thin infrastructure.

Prison cell blocks are currently being pressed into service as temporary patient enclosures in the US. We do not agree with this approach for many reasons, especially those within our knowledge domain. There is no evidence, of which we are aware, from other countries considering the use of prisons as viable settings to increase health service capacity; this may be because of existing overcrowding issues in the prison populations of many developed countries. In fact, there are concerns that prison environments could be ideal settings for the virus to spread, putting at risk the health of prisoners and prison staff. We are concerned therefore about the collateral effects of their use, and we believe there to be much better and equally accessible solutions.

Cruise ships have been offered by at least one cruise-line operator as temporary hospitals. Again, we do not agree with this approach for many reasons, especially those within our knowledge domain, and we are concerned about the collateral effects of their use (exceptions to this stance are purpose-built mobile hospital ships). 

The geometries of a space-efficient cruise ship exacerbate the geometric discussions cited above. Stateroom doors are typically only two-feet wide, which won’t allow a gurney to pass. Corridors are akin to economy hotels, which create substantial difficulties in manoeuvring patients, and furnishings are fixed, requiring renovation. Cruise ships simply won’t work.

It’s feasible that these options may be able to be converted in emergency situations while operating sub-optimally. However, we stress that these decisions will require professional counsel and guidance from experienced architects, andwill likely require construction intervention – a process that takes too long during an emergency.

If policymakers insist on such solutions, they must also reach into their respective departments to ensure that authorities that have jurisdiction in reviewing and approving these projects are technically capable of rapidly assessing design intent and the resulting construction, so that patients and caregivers remain safe and the primary issue of a patient’s curative outcome is realised. We recommend engaging qualified board-certified healthcare architects¹⁶ active in their knowledge community¹⁷ to act as advisors.

Global lessons and observations                                                                                                       

The ‘surge capacity’ of a health system at the workforce-equipment-facilities intersection is a critical part of any resilience strategy, and architects and their associated design discipline professionals are essential to pandemic solution development. The pandemic has revealed a significant discrepancy in ICU bed numbers between different countries. The focus for years across most geographies has been on reducing bed numbers, and diagnosing and treating in the community to keep people out of hospital. But in a pandemic situation, those beds need to be scaled up quickly in appropriate facilities. Stories of  corridors being redesigned as critical care wards in the space of a week are starting to emerge in Europe, as hospitals try to innovate to manage the problem.

China’s ability to build hospitals in a matter of days and use all types of other facilities to house patients sets a pandemic design precedent. This was made achievable because of advanced planning and pre-established supply chains. However, while no one imagines these hospitals would meet acceptable standards, the flexibility to build and then commission a whole new hospital in such a short time to deal with a crisis and address the supply/capacity issues offers lessons from which we must learn.

Critically vital resources include equipment and staff, but infrastructure design and buildings need to be considered in tandem. From a broader public policy standpoint, will we design our cities differently in the future to manage risk in the face of future pandemics? This is a public health crisis that is rapidly becoming a healthcare and medical crisis, and the built environment should be an important part of the solution. Our healthcare systems need to be more resilient by encouraging digital technology in lieu of vehicles that accelerate disease transmission. We also need to make our cities and communities more resilient so we can cut such diseases off close to their source before infecting the healthcare system.

Specific recommendations for a path forward                                                                               

Practical and rapid solutions are available based on current and emerging design and construction technologies. We recommend the following:

• policymakers convene qualified professionals to ideate suitable and rapidly deployable solutions for housing the medical interventions necessary to combat the novel coronavirus;
• consider 3-D printed building modules;
• consider modular buildings components;
• consider converting over-the road trailers or cargo shipping containers placed in abandoned parking lots for basic shelter, and then integrating and aggregating them into inpatient units; and
• at a public health level, we call for urban design and architecture to be leveraged and engaged in developing future-state solutions.

References

1. Florence Nightingale, Why do we remember her? The National Archives of the United Kingdom; website accessed 20 Mar 2020.
2. Board-certified healthcare architects. American College of Healthcare Architects; website accessed 20 Mar 2020.
3. Certified healthcare facility manager American Society for Healthcare Engineering of the American Hospital Association; website accessed 20 Mar 2020
4. Adoption of the FGI Guidelines. Facility Guidelines Institute; website accessed 20 Mar 2020.
5. Waldman, A, Shaw, A, Ngu, A, and Campbell, S: Are hospitals near me ready for coronavirus? Here are nine different scenarios. ProPublica; website accessed 20 Mar 2020.
6. Warner, J: Why we are not doing enough to stop the pandemic (in simpler math). Medium; 19 Mar 2020; website accessed 20 Mar 2020.
7. Budds, D: Design in the age of pandemics. Curbed, Vox Media; 17 Mar 2020; website accessed 20 Mar 2020.
8. Manaugh, G, and Twilley, N: Untitled upcoming book. MCD Books; Spring 2021.
9. Manaugh, G, and Twilley, N: ibid.
10. Flannery, J: Health care facilities & COVID-19 safety: what you need to know. American Society for Healthcare Engineering of the American Hospital Association; 17 Mar 2020; website accessed 20 Mar 2020.
11. Sheerin, M: COVID-19 guidance. American Society of Heating, Refrigerating and Air-Conditioning Engineers; Mar 2020.
12. Interim guidance for healthcare facilities: preparing for community transmission of COVID-19 in the United States. Centers for Disease Control and Prevention; website accessed 20 Mar 2020.
13. Flannery, J; ibid.
14. Sheerin, M; ibid.
15. Waldman, A et al; Warner, J; ibid.
16. Certificate Holder’s Directory. American College of Healthcare Architects; website accessed 20 Mar 2020.
17. Academy of Architecture for Health of the American Institute of Architects; website accessed 20 Mar 2020.