The coronavirus pandemic created a spring like no other for the healthcare industry. By mid-March, as infections began to rise across the U.S., healthcare organizations were looking for ways to increase bed capacity while simultaneously shutting down elective surgeries and nonessential services in anticipation of a surge in infected patients requiring care. In addition to transforming clinical areas to ICU-like environments, efforts included the construction or transformation of existing facilities into field hospitals or alternate care sites. New operational and care policies were outlined to identify spaces to handle COVID-19 patients, separate infected and non-infected patients, and protect patients and staff from exposure, even as understanding about the coronavirus and its transmission were still emerging.

“In retrospect, it felt like we hit a brick wall and had to pivot very quickly to address the growing concerns and needs,” says Jeff Hankin, senior principal and U.S. health sector engineering lead at Stantec (San Diego). “Things seemingly changed overnight or at least within a week’s timeframe.”

Julie Kent, director, facilities planning and integration, at Trinity Health (Livonia, Mich.), says at the start of the COVID-19 surge planning in mid-March, Trinity Health first looked at using vacant units, shell spaces, and decommissioned facilities to accommodate an anticipated increase in patient volumes. “The requirements for these types of projects were time and money, which weren’t available,” she says. For example, decommissioned units were estimated to need 90 days to renovate for reactivation. “Safety was our first priority, but we’re also stewards of our finances,” she says. “How could we justify spending on facilities that might not be ready before the bed capacity was needed or wouldn’t be needed in the future?”

After re-evaluating its options, the organization determined that converting existing private patient rooms to semiprivate, using alternative patient care areas such as prep and recovery departments, and bringing a few closed inpatient units back online for COVID-19 patients were its best options. Additionally, some of its hospitals worked with the Federal Emergency Management Agency on off-site alternate care sites, where nonacute patients could be treated, while others erected tents for patient screening and ED overflow. Fortunately, Kent says, most of Trinity’s hospitals saw patient curves flatten by May without reaching crisis levels, which reinforced the strategy to increase patient capacity inside existing clinical areas of the hospital and minimize the time and money spent on alternate care site solutions that were never utilized.

However, after all that preparation, another realization was hitting the industry, Hankin says. “People put so much attention into providing care sites and additional spaces for surge capacity that they soon realized it kind of choked the revenue-generating machine from any healthcare organization because non-COVID-19 patients were often moved and elective procedures were canceled, and then the patients—except in a few key areas—never really showed up in the volumes that were expected,” he says. At Trinity, Kent says net patient revenue decreased $175.3 million in March 2020 compared to March 2019, while direct operational costs rose $14.2 million in the last two weeks of the month alone.

Facing significant revenue losses, many healthcare organizations began holding back on some of their capital expenditures or postponing projects on the boards, while looking for infrastructure, care model, and operational changes that could be implemented in the immediate future to start bringing patients and elective surgeries and procedures back safely, Hankin says. For example, when Trinity began shifting from surge preparations to recovery planning in late April, Kent says state regulatory agencies required health systems to show that they had enough inpatient bed capacity and personal protective equipment (PPE) on hand to support COVID-19 patients prior to reopening non-emergency clinical services. The Centers for Disease Control and Prevention also required facilities to designate non-COVID-19 care zones. “As part of reactivation, there were a lot of dials that had to be aligned between clinical operations and facilities space planning,” she says.

This reality—getting hospitals back to as normal as possible while still holding a portion of a facility or physical assets for COVID-19 patients—is one of many challenges facing the healthcare design industry today, Hankin says. As a result, it’s driving new conversations between healthcare organizations and their design partners about what’s been learned so far and the lessons that can be applied to projects going forward, both in the short- and long-term. “I see organizations struggling to prioritize what those most important things are that they have to do right now, all while they’re seeing the revenue streams and cashflow continue to stay low,” he says.

Addressing surge
Looking at the lessons to come out of the spring, Hank Adams, senior vice president and global director of healthcare at HDR (Dallas), says he anticipates healthcare organizations will think differently about surge capacity going forward. “Some of the models that were built out or presented are just too difficult to staff, equip, and actually activate,” he says. For example, hospitals with existing shell space that could be converted easily or already had infrastructure in place had an advantage over using arenas or other facilities such as hotels that require major conversion to serve as temporary care sites. “They were more cost effective and a bit more patient- and caregiver-centric,” he says.

There were also lessons on alternate care facilities and how they were used in the field. For example, Trinity’s alternate sites represented 5 percent of the organization’s overall surge plan, but not all staff felt comfortable transferring high-acuity patients to tents, so they were used mainly for patient testing and triage and not overnight patient care. “It’s not the first investment we’d be looking to make in the future,” Kent says.

Other design professionals suggest creating a plan to activate alternate care facilities in phases to prevent overbuilding in the future, while another strategy for systems with multiple locations is to designate one site as a COVID-19 hospital to lessen disruption to the care network.

Looking for long-term solutions to help lessen the impact on overall operations and the ability to deliver care to patients with high acute needs, Adams says he’d like to see more widespread adoption of conversion-ready rooms in new construction and renovation projects. This concept would include patient rooms and units, as has been done in the past, but extend to prep and recovery departments “so that all the different departments of an acute care facility can be converted to a higher use that can help handle a surge or higher care needs,” he says.

HDR is also assessing projects in progress to see if nonclinical areas should be prepped with medical gases and emergency power capabilities to allow those areas to be used as temporary care sites. “People are looking at hospitals and recognizing that every square foot is precious real estate and is there an ability to convert space to a higher usage, as needed,” he says.

Beyond the walls of hospitals, experts are also rethinking site planning to address how surge (or future epidemics/pandemics) can be better addressed on-campus, including looking at how people arrive, how parking is organized, how facilities might queue patients, what touchless technology could be used to register patients and evaluate their health, and how the site might be used to stage patients outdoors before you even start to bring them inside. Additionally, designers are considering what power, gas, and data connection needs those temporary structures might require to operate. “There’s a lot of talk now, too, about expanding drive-through testing if that continues to grow, and maybe even drive-through inoculations,” Adams says. “There’s even an idea that maybe an emergency department has drive-through capability where you’re evaluated in your car, as a better way to protect patients and caregivers.”

Rethinking interiors
In concert with new facility layouts and site configurations, the coronavirus pandemic is driving organizations to reconsider infection control strategies in interior spaces. Tiana Lemons, senior associate at Orcutt/Winslow (Nashville), says she’s rethinking materials choices and how to declutter spaces to reduce build-up of dust and particles, which can spread viruses. “Maybe we need to design more simplistically,” she says. “I love texture, but maybe in a healthcare setting texture isn’t something we should be using.” Rather, she says, smooth, curved surfaces and edges may be more appropriate while also communicating an image of cleanliness.

She also anticipates more solid surface materials being used in furniture and casework, as well as a move toward more vinyl and polyurethane products to further support infection control measures while being able to withstand strict cleaning protocols. “We had a lot of these ideas already, but the clients didn’t want to spend the money for it. So a lot of those things got value engineered out,” she says. “I think that’s not going to happen as much moving forward.”

Along with additional signage that facilities have been adding to communicate safety reminders or direct patients and family members to PPE stations where they can get face masks and gloves or wash their hands, Lemons expects to see more demand for touchless technology controls in acute care environments for doors, elevators, light switches, and window shades to reduce the number of shared surfaces people touch. Within patient rooms, she says she’d also like to see more widespread adoption of communications technology, including cameras and monitors, that could help address the issue of isolation that many faced. This could allow patients to “visit” with loved ones while enabling family members to remotely monitor a patient’s care. “I think it could mean a lot to patients and their families,” Lemons says.

Looking forward
As some states continued to see surges of COVID-19 cases in the summer months, healthcare organizations are balancing finding the right solutions for the current situation while also looking for long-term solutions that answer needs well beyond what might be a second wave in the fall, Adams says. “A lot of our clients have projects that are in early stages of design right now and are eager to talk about the lessons learned from the post-pandemic environment and how to apply those to their new facilities,” he says.

For example, he says there’s a lot of interest in mechanical/electrical/plumbing systems, specifically for air filtration, and using new technologies to minimize distribution of pathogens within the mechanical ventilation systems. “It’s a really good time to talk about engineering design strategies to either convert a patient unit to negative pressure; increase that kind of capacity; or consider filtration, UV light, and directional airflow to prevent airborne and aerosol contamination outside the patient care space,” he says.
Patient room layout is another area that might be worth rethinking, Kent says.

Converting private rooms to semiprivate represented nearly 25 percent of Trinity’s surge plan to increase inpatient capacity. “Based on what we knew about the coronavirus at the time, a semiprivate room could accommodate two infected patients with adequate distance between beds. This may not be the case in the future,” Kent says, “Designing future spaces for flexibility will be critical to handling another virus or pandemic. Is planning rooms to rapidly convert from private to semiprivate the right approach? It’s a toss-up.”

Adams adds that some solutions to consider are on a smaller scale. For example, in the wake of COVID-19, healthcare facilities must address storage needs to house all the PPE supplies they may want to have on hand. “I think the healthcare systems that have experienced the real peak demand in the Northeast, they’ve suddenly realized that in order to house the extra supplies and make sure it’s all current and ready to be deployed, that requires a lot of space,” he says.

Another outcome of the pandemic has been a rise in telehealth, with many organizations and design professionals anticipating increased usage to continue post-pandemic. Hankin says he’s already having discussions with clients about increased bandwidth needs, additional server space and IT equipment, and on-site or off-site data center spaces, in addition to providing office space with proper lighting and acoustics to support virtual care sessions.

And while these concerns—and the solutions being sought to address them—add a new layer of complexity to an already intricate design industry, many healthcare designers are embracing the moment to rethink the status quo and improve facility design.
“It’s a really good opportunity because the truth is we should be using technology in a better way, we should be using more touchless technology, we should be using telehealth,” Adams says. “When patients show up for appointments and procedures, they shouldn’t have to sit in waiting rooms for hours on end and be exposed to large groups of people. In a lot of ways, I think this is going to force a better healthcare experience long term, if we do it right.”

Anne DiNardo is executive editor of Healthcare Design. She can be reached at