The COVID-19 pandemic has upset the delicate balance of healthcare delivery systems around the world, raising all sorts of questions regarding responsibility, coordination, testing, sheltering in place, face masks, resilience, safety of health personnel, patient care, medicine, logistics, supply chains, patient transportation, and appropriate alternative care sites to handle patient surges.

As we figure out the appropriate responses, the industry also needs to ask itself a more basic question, “How do we prepare for all types of unexpected natural or manmade shocks?” These events can range from hurricanes, floods, typhoons, tsunamis, fires, cyclones, and tornados to bioterrorism, biowarfare, radioactive incidents, military attacks, and any other conceivable threats.

In an effort to raise awareness and analyze the issue of COVID-19, here’s a look at planning considerations and solutions that can help the industry handle the current pandemic, while also becoming better prepared for future events.

Alternative care settings: One solution is to create a backup system of surge health facilities, or alternative care settings. Why is this important? Because with a COVID-19 or other pandemic, it’s important not to risk other patients’ health and safety by bringing highly communicable disease patients into an existing hospital, where they can spread the disease to other patients and medical staff. Another simple solution would be to design single-bed rooms large enough to accommodate a second bed and thus double the size of a 250-bed hospital into a 500-bed hospital simply by adding a second bed.

Types of health facilities and hospitals to handle surge would include:

  • Transportable health units: Prefabricated structures, tent structure, military field hospitals, transportable health units, and shipping containers. (From a facilities standpoint, the use of tents and various prefabricated assemblies have proven to be an effective method of providing easy access in the community.)
  • Mobile Health Units: Emergency Response Vehicles, ambulances, river health boats, hospital ships, hospital trains, vans, tractor trailers, quick conversion of fleet vehicles (such as U.S. Postal Service trucks, Fed EX and UPS vans), buses, and helicopters.
  • Existing buildings: Existing urban community and rural hospital and health facilities, ambulatory care facilities, long-term care facilities, and emergency sites.
  • Other Alternative Sites: Grade schools, high schools, colleges, community centers, churches and synagogues, shopping centers, motels, hotels, convention centers, sports arenas, and recreational centers.

Guidelines, codes, and regulations for healthcare facility design: We have guidelines, codes, and regulations for health and hospital facility design and construction, including the Facility Guideline Institute’s Guidelines and ASHRAE standards, which address the issues of frequent air changes, negative air pressure, and filtration—important elements of healthcare disaster planning under normal conditions. But the latter need to be developed much further for surge conditions by qualified task forces. Issues of operations and enforcement of licensure are important in requiring the codes and standards to be improved and followed by hospitals.

Develop surge health and hospital facilities legislation: During the Great Depression, Congress and President Franklin D. Roosevelt enacted legislation to create the Works Progress Administration (WPA), which created public works projects in order to create jobs for the multitude of people unemployed during the depression. In the 1940s, the Hill-Burton Act was signed into law by President Harry S. Truman, resulting in many healthcare and hospital facilities being designed and built. Why can’t we create a similar program now that would result in many new jobs during the current pandemic? At a time of tremendous economic dislocation what could be more worthwhile than to create a backup system of facilities that could be quickly adapted to accommodate patients and medical staff in emergencies. It would involve community action in collaboration with local, state, and federal agencies.

Legal agreements concluded ahead of time: Arrangements and legal agreements need to be undertaken with hotels, schools, convention centers, and other types of facilities ahead of time, so that when the need arises the facility will be made available for the designated purpose of an alternative healthcare site. Agreements must include important details such as storing of beds, linen, masks, clothing for staff, medical supplies, and countless other items.

Healthcare staffing: There needs to be healthcare auxiliaries set up to staff these facilities when the need arises. Without additional healthcare professionals, we will be dealing with empty facilities.

Physical, mental, and spiritual effects on people: The cumulative effects of a pandemic like COVID-19 on the physical, mental, and spiritual health of patients and medical professionals cannot be underestimated. Increases in mental and physical health problems, including increases in suicide, have been reported extensively as a result of sheltering-in-place and other COVID-19 control procedures in the workplace, public spaces, education, and the like. Access to regular care, including medical treatment and necessary surgery, has been limited, too. Distance consulting has aided in addressing this problem, but effective procedures must be established to provide direct patient care where necessary.

Communications systems: Comprehensive and resilient communication systems with police, fire, and emergency services and the public are vital to effective and responsive management of the pandemic and/or future disasters. Communication systems need to be properly located within or near health or hospital facilities, with secure backup at remote sites, along with clearly coordinated plans throughout the country.

Prevention, education, early detection, treatment, and rehabilitation of disease: Once the threat is determined, a preventive program, including education, early detection of disease, treatment, and rehabilitation must be initiated with clear and decisive protocols.

Telemedicine: When shelter-in-place orders were enforced early during the COVID-19 pandemic, many people began communicating with their physicians via Facetime and other forms of video conferencing. This enabled patients to stay away from clinics, thus avoiding exposure to COVID-19. The possibilities of telemedicine are enormous. This effective technology must be established widely and utilized in order to provide safe, acceptable care for both the patient and the provider.

Testing stations for COVID-19 virus: Each disaster situation is different, however some basic principles that should be considered to incentivize people to be tested include location, access, staffing, equipment, hours of operation, and follow-up. Future considerations might include permanent drive-through provisions at all testing stations and the inclusion of testing stations at outpatient centers, doctor offices, pharmacies, and other healthcare facilities.

Tracking of communicable diseases: Electronic technology to help tracking of clusters of disease patterns and disease hot spots is vital information needed to focus on containing the spread of disease.

Protection of medical personnel: Without medical personnel being thoroughly protected through proper personal protective equipment (PPE), we risk losing critical staff to the virus itself. A top priority is the development and distribution of PPE. The entire approach, including apparel, breathing functions, and temperature control within the PPE apparel itself, needs further research and development. We cannot do enough to protect our medical personnel, who risk their lives every day for us.

Robotics: Further work is necessary on developing robots to help on emergency vehicles as well as within congested areas of healthcare facilities that are treating infected patients. Robots can also be sent into contaminated areas of the hospital to perform specific medical tasks related to nursing and inventory of medical supplies, without exposing healthcare personnel to communicable diseases.

Security: It’s possible that in the midst of a natural or manmade disaster people and vehicles can converge on and overwhelm emergency facilities. The scene could be total chaos, with hundreds and perhaps thousands of people trying to get medical attention at the same time, which can lead to desperate patients willing to do anything to get medical attention. Therefore, the security for medical staff, patients, and their families will be a major concern. Proper planning coordination and regular simulated drills, including planning for a variety of different possible scenarios, need to be undertaken. Some scenarios would call for a triage concept with different zones surrounding the emergency facility, utilizing large spaces, and quickly erecting emergency tent structures to accommodate patients and medical staff.

COVID-19 attacked human populations with devastating results. The response to this disaster and future ones needs to be decisive, swift, and coordinated. Our society needs to recognize the magnitude and the seriousness of COVID-19 and comprehensively organize to fight it and defeat it. Communities may have been caught off guard by the COVID-19 virus, but with careful planning we can be better prepared for future possible natural and manmade disasters.

We’re all in this together and, in a coordinated effort with appropriate funding and planning, we can rise to meet the challenge of COVID-19.

Ronald L. Skaggs, Chairman Emeritus, HKS Inc., FAIA, FACHA, FHFI, LEED AP, is an adjunct professor of architecture, at Texas A&M University. He can be reached at Joseph G. Sprague, FAIA, FACHA, FHFI, is a principal and senior vice president, HKS Inc., and past president of the Facility Guidelines Institute, American College of Healthcare Architects, and the AIA Academy of Architecture for Health. He can be reached at George J. Mann, architect, AIA, is The Ronald L. Skaggs, FAIA, Endowed Professor of Health Facilities Design, College of Architecture, at Texas A&M University, and founder and Chairman of the Resource Planning & Development Group. He can be reached at

This fall, the Architecture for Health Weekly Visiting Lecture Series, hosted by Texas A&M University, is devoted to the topic “Surge Capacity: Health Care Preparedness  for all Hazards Response:  including Alternative Care Settings, Reinstitute Shuttered Hospitals.” Click here for more information.