Architecture Is a Critical Ingredient of Pandemic Medicine

An open letter to policymakers on the essential role of architecture in addressing human health and health care facility design during the coronavirus COVID-19 outbreak and for future crises.

By William J. Hercules, FAIA, Dr. Diana Anderson, Marc Sansom

The built environment is a critical part of pandemic solutions and emergency preparedness—consider Florence Nightingale’s experience.

Traditional capacity is limited, and expedient alternatives pose many challenges, resulting in unacceptable unintended consequences.

Policymakers must immediately convene a task force of qualified professionals to develop acceptable and rapidly deployable solutions for housing the medical facilities necessary to combat the COVID-19 crisis—and make those solutions available globally.

Practical and rapid solutions are available based on current and emerging design and construction technologies.

Urban designers and architects must be leveraged and engaged to develop future-state solutions, so our current improvisational response is not repeated.

The Architecture of Patient Environments, a Critical Component of Saving Lives

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. We argue that the built environment is a critical part of pandemic solutions and emergency preparedness.

Policymakers may believe that any enclosed space suffices—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 don’t have access to vital information or haven’t been properly advised. 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 health care architects and certified health facility engineers, are key and valuable resources for rapid adjustments to current hospital and non-hospital infrastructure—repurposing old health care buildings, erecting temporary structures, and considering emergency preparedness in our building’s codes and design guidelines. Current space utilization in hospitals can be quickly evaluated by these experts to maximize existing areas for use.

With the rapid worldwide spread of the SARS-CoV-2 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 the fact that we have no current vaccine or effective treatment available, we must turn to non-pharmacologic means—including social distancing, isolation, and quarantine—which depend upon the built environment. Our homes, neighborhoods, health care 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 U.S. in several scenarios, concluding that “vast communities in America are not prepared to take care of the COVID-19 patients.” 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. In the face of airborne pathogens communicating to humans so freely, “the only thing we have left is quarantine,” asserts critic Geoff Manaugh, who is writing a book on the topic. At least temporarily, Manaugh believes, “We have to return to this kind of medieval spatial response to disease control, which means that architecture and urban design suddenly become medical.”

Specific Qualities of Space Enclosures for COVID-19

While the American Society for Healthcare Engineering (ASHE) and others have clarified the health facility–related recommendations from the Centers for Disease Control and Prevention, the devil is in the details. Different patient conditions require different physical environments. The design of these environments of care does matter. Architects are ready and positioned to ensure that built space has positive effects on health outcomes and how care is delivered.

If patients require hospitalization according to emerging treatment modalities for COVID-19, 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, or AIIR, like the rooms used to resist tuberculosis. Both have specific air-filtration and -exhausting requirements to protect patients within, caregivers, and others in adjacent spaces. However, typical hospitals may have a small number of such rooms, and some hospitals may have none.

Existing hospital rooms may be modified to accommodate these specific air pressure requirements, and ASHE and others have documented some of these strategies. 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 available acute- and intensive-care beds will be exhausted quickly by the rising number of COVID-19 patients. There are at least three types of environments of care that have various degrees of suitability to house the influx of patients: current hospitals; private homes, nursing homes, and hotels; and quickly constructed alternative locations such as vacant office buildings, prisons, and parking lots. Each presents specific challenges from a life-safety and building-services standpoint. Evaluating them will require careful triage by qualified professionals, including architects and engineers, as well as rationing of available caregivers, therapies, environments, and equipment, all under evolving circumstances.

Existing Hospitals are the best locations for patients who need focused medical treatment for COVID-19 and have other medical comorbidities: Some of these conditions will require critical care, involving highly specialized teams with specialized equipment that are co-located. These facilities and their systems may or may not be quickly adaptable, regardless of actual spatial capacity. Infrastructure adjustments may be necessary, including building-support systems such as HVAC and power. These are the most regulated of the environments of care, and while modifications may be allowable, care should be taken to engage a credentialed health care architect to not adversely affect the 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. Such facilities do not have caregiver deployment systems, and the qualities of the care environments are diverse and are unlikely to meet reliability standards for consistent outcomes. Specialized treatment equipment such as ventilators are very unlikely to be available in this context. Personal protective equipment must be managed, along with the monitoring strategy and its associated equipment. While home, nursing home, and hotel space 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, and other infrastructure 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 door to each bedroom must remain closed, the existing air return grilles closed and sealed, and the entry used by caregivers in protective gowns should be sealed. These measures will create differences in air pressure between the sealed space and the rest of the facility, posing 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, among other measures. The life-safety systems must be capable of supporting patients who may not be able to evacuate the building on their own in the case of an emergency. We recommend that a floor or zone of a floor be designated for such patients, as that floor or zone will be considered contaminated in its entirety, and cordoned off from the remainder of the building with elevator access limited to caregivers only. The HVAC system affecting such a 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.

Additionally, hotels have different geometries than hospital inpatient units. Hospital corridors are 8 feet wide to facilitate beds passing and rotating a gurney to enter a patient room. Hotel corridors are 5 or 6 feet wide and have narrower doors. Having adequate space to support active nursing is another issue. A typical modern inpatient unit in a hospital requires a significant amount of 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, and other purposes. 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 to sufficiently modify a non-purpose-built facility to meet 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 for use as temporary patient enclosures, but such facilities are typically not conducive to patient-appropriate life-safety, limiting the number of patients they can house. Adequate and patient-appropriate life-safety, HVAC, normal electrical power (and perhaps emergency power), secure communications and data systems, and more need to supplement the existing thin infrastructure.

Prison Cell Blocks are currently being pressed into service as temporary patient enclosures in the United States. We do not agree with this approach for many reasons, especially those within our knowledge domain. We have found no evidence that other countries are considering prisons as viable opportunities to increase health service capacity, possibly due in part to existing overcrowding issues in the prison populations of many developed countries. Prison environments may become incubators, placing prisoners and prison staff at risk of contracting COVID-19. There are much better and equally accessible solutions. At least one cruise line operator has offered cruise ships for use as temporary hospitals. We do not agree with this approach either, for many reasons, especially those within our knowledge domain. (Purpose-built mobile hospital ships are exceptions to this stance.) The geometries of a space-efficient cruise ship exacerbate the issues noted above, with hotels. Stateroom doors are typically only 2 feet wide, which won’t allow a gurney to pass. The corridor widths are akin to those in economy hotels, which create substantial difficulties in maneuvering patients. Also, the furnishings are fixed, requiring renovation. Cruise ships simply won’t work.

While these options may be able to be converted in emergency situations while operating suboptimally, our point is that these decisions will require professional council and guidance from experienced architects, and will likely require construction intervention—a process which takes more time than an emergency expects or allows.

If policymakers insist on such solutions, they must also reach into their respective departments to make sure that authorities who have jurisdiction tasked with reviewing and approving these projects are technically capable of rapidly assessing design intent and the constructed result so that patients and caregivers alike remain safe and the primary problem of a patient’s curative outcome is realized. We recommend engaging qualified health care architects active in their knowledge community to act as advisers.

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 other design professionals are essential to pandemic solution development. The COVID-19 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 people in the community to keep them out of the hospital. But in a pandemic situation, those beds need to be scaled up quickly in appropriate facilities. Stories of corridors being repurposed 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 to use all types of other facilities to house patients sets a pandemic design precedent. Such measures were possible because of advanced planning and existing supply chains. 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 can serve as a lesson.

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 health care/medical crisis, and the built environment should be an important part of the solution. Our health care systems need to be more resilient by facilitating the use of digital communications instead of face-to-face interactions between health care professionals and patients, which accelerate disease transmission. We also need to make our cities and communities more resilient so we can cut such diseases off close to source before infecting the health care system.

Specific Recommendations for a Path Forward
Practical and rapid solutions are available based on current and emerging design and construction technologies:

We recommend that policymakers convene qualified professionals to develop rapidly deployable solutions for the medical facilities necessary to combat this virus.
Consider 3D-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 aggregating them into inpatient units.
At a public health level, we call for urban design and architecture to be engaged in developing future-state solutions.

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