A pandemic is the personification of a situation that is out of control, and it’s easy to feel anxious or helpless. Information is the antidote. Correction: Good information. Accurate information.
Today we have a Guest Post from Suzanne, our resident Architect Extraordinaire. She specializes in buildings related to healthcare, and she is here
to tell us everything she knows about hospital design to share a bit of her practical knowledge and expertise in this area, and to answer our questions.
With that, I give you Suzanne!
Good afternoon, everyone. With all that is going on in the world, there have been a lot of questions about the built environment of healthcare facilities, and I thought it might be helpful if I gave a high-level primer on the issue.
For those of you who don’t know, I am a licensed architect and planner practicing in the healthcare market. I have been practicing for ten years and have been licensed for six years. I don’t want to talk about my company, clients, or projects specifically, but I am happy to share what I know here based on my professional experience. I hope it answers many of the questions you have. The two questions that I’ve heard the most are Why don’t we have more intensive care beds available? and Why don’t we just take some other building and turn it into a hospital? Bear with me here… there are reasons.
First off, there’s a few things to understand about buildings in general. There’s an array of codes and regulations that govern the built environment. These vary by municipality, county, and/or state, and there are also federal laws such as the ADA (Americans with Disabilities Act) and CMS (Center for Medicare and Medicaid Services) regulations that apply to buildings. However, most building codes in the US and Canada are based on the International Code (I-Code) series. For example, California has the California Building Code (CBC), but it’s really the International Building Code with some elements added and changed to apply to conditions specific in that state. The Building Code is where you find most of the governance for architectural and structural elements, most notably types of construction, allowable occupancy, means of emergency egress (this means how to exit the building), and so on. There are also codes and regulations around building systems, such as mechanical systems (HVAC), electrical systems, energy performance, plumbing, civil engineering, and more. Then there’s zoning regulations, which is another enormous—and boring–topic for another day.
I am not a code expert, and there’s no need to get into the particulars, but the essential thing to remember here is that the codes are written around a concept that the larger a building may be (either in height or area), and the more difficult it is to exit, and the more important it is to the functioning of society… that building is designed to be more robust. Buildings that are small, easily replaced, and don’t have a lot of occupants—such as houses and small multi-family residential buildings—are not really designed to survive events like fires. In contrast, a building like a 70-story high-rise office tower or an international airport terminal needs to remain structurally sound for a relatively long period in order to get everyone out safely in the event of an emergency. Hospitals tend to be large buildings, with a lot of risks present (like bulk oxygen). Also, they contain a lot of people, many of whom cannot evacuate under their own power, because they’re in wheelchairs, or have broken bones, or are under anesthesia, or are in the throes of dementia, etc. And in the event of an emergency such as a natural disaster, it is critical to the entire city/town around the facility that it remains operational. So the architecture and structural design of these buildings is significantly different than, say, a low-rise apartment building or strip retail center. I hope this sheds light on a lot of the questions people have about why one type of building is not easily repurposed into another.
Secondly, and specific to hospitals, there are also spatial and operational codes and standards that are meant to protect public health, safety, and welfare. These vary somewhat by state, but are all mostly written to address the same concerns. There are a few big issues present in hospitals that have led to significant regulation. First and foremost is the exceedingly high rate of hospital-acquired infections. This has led to big changes in the way hospitals are designed. Again, keeping this high-level… we now have to have more and separate spaces for patients. Other than in a few very specific situations, we don’t do shared hospital inpatient rooms anymore, and we almost never do open wards. We build more bathrooms. We build negative-pressure rooms for airborne infection isolation. We have more spatial clearance around operating tables. We install handwashing sinks all over the place. We use interior materials that are resistant to bacteria and viruses. Another significant issue has been accessibility for the disabled and patients of size. Essentially, people are bigger than they used to be, and modern hospitals are designed to accommodate those patients. A third issue of significance has been trying to reduce injuries and distances traveled by nursing staff by improving visibility and designing their space to their workflow. There are also issues around reducing medication errors, increasing security (think drugs and guns), protecting patient privacy, and more.
All of this is to explain why hospitals are such specialized environments, and as such, why they are so expensive and time-intensive and complicated to build.
In understanding why hospitals are built the way that they are, it’s also important to consider the economic environment. Healthcare buildings are incredibly expensive, because healthcare is incredibly expensive. Most hospitals are owned by corporations (either non-profit or for-profit), not the public, and it is a struggle to remain financially solvent. Certain service lines in hospitals are more profitable than others, and the business case for a hospital is written around that reality. A couple of generations ago, hospitals were fairly low-tech places, and you could check yourself in for a few days if you felt a little bit under the weather. That is obviously no longer the case. Patients have to meet criteria for admission, and length-of-stay is watched closely by insurance companies. Medicare is very strict about reimbursement. Ergo, health systems generally want to offer certain kinds of care and sometimes want to avoid others. Surgery tends to be very profitable. Behavioral health, especially prior to the passage of Obamacare, is not. The typical acute-care hospital room is relatively cheap to build and operate. Intensive care is not. The dream for a hospital system is to give you an expensive surgery after taking some expensive images and then send you home to be cared for by a home health worker, or your own family.
So, when wondering why the country is now facing a dramatic shortage of intensive care beds, the answer is: because they’re really expensive to build, they’re expensive to staff, and if we built enough to handle a crisis like COVID, they would mostly sit empty once the crisis is over. When building a hospital, every dollar has to support a business case. Beds have to be occupied a certain percentage of the time in order to justify their expense. Every square foot that I design has to return value, as it is an investment of capital. The shortage that we are facing is the result of thinking of hospitals as businesses that need to be self-supporting rather than investments in the health of a whole population.
I don’t want to make health systems sound greedy or nefarious. Most of the people I interact with are devoted to good patient care. Often, the C-suite people have clinical or research experience and truly want to do the right thing with the resources they have. The developers and project managers, for the most part, take the responsibility of building a place where lives are saved incredibly seriously. But the reality that they live in produces the results that we have.
With respect to COVID, it’s not going to be easy to ramp up intensive care capacity in time to meet this challenge. What is likely more feasible is going to be identifying infected people earlier in their disease process and hopefully giving them treatment to manage their symptoms before they need that ventilator. In the meantime, hospitals are going to end up using every available space they have for patients, such as pre-operative and post-anesthesia care areas (or maybe even labor and delivery areas, oh my God), in order to accommodate as many patients as they can. I believe that they’ll also try to use temporary facilities for less-sick people in order to reserve the hospital resources (medical gases, equipment, emergency power) for the sickest people.
If health systems can get their hands on more ventilators, I can imagine some field-hospital-esque scenario if it gets to a last resort. But a big open ward in, say, a high school gymnasium is really not a good environment for people who are infectious, and it certainly isn’t going to be good enough for the next pandemic. But there’s not any great options here. Workers who can build big, complicated buildings like a hospital are a limited resource. The supply chain for building materials is long. These buildings are expensive and take a long time to construct, and health systems don’t really build for these types of surges. There’s not enough healthcare staff out there, anyway. COVID is a 100-year event, and there are very few times we do anything in society for 100-year events. Flattening that curve and finding some effective treatment or a vaccine is what we need to do.
I’ll hang around for a bit to answer questions in the comments. I hope this has been informative and un-boring. Cheers.