To help shed light on how the unfolding COVID-19 coronavirus outbreak stands to influence our healthcare system—and the design of these environments—Healthcare Design spoke to expert Robert Counter, AIA, healthcare director and senior associate at Leo A Daly, for insight on what to expect and how facilities can best respond.

Healthcare Design: Share with our readers a little bit about your background and the firm’s involvement in designing for threats like coronavirus.

Robert Counter: Leo A Daly was one of the first firms to specialize in biocontainment patient care units, now referred to as special pathogen units (SPUs), by incorporating our experience designing BSL-3 and BSL-4 labs for the government into our healthcare practice. In 2014, the Nebraska biocontainment unit in Omaha, which we designed, was activated to treat an American Ebola patient, and has since been used to treat several patients with the virus.

For the past five years, I’ve been leading Leo A Daly’s Los Angeles studio in designing an Ebola/SPU as part of the CDC’s efforts to build regional referral centers throughout the country.

This has involved working closely with the client to study various locations on a major urban hospital campus and working with state and local regulatory agencies on the design requirements. To aid in the design, we visited existing SPUs around the country and met with clinicians to gather lessons learned and incorporate them into the design of this next-gen unit.

From your perspective, what are your initial thoughts as you watch the Covid-19 story unfold?

My initial impression is that COVID-19 will have less impact to hospitals in the U.S. than the current flu, which is also deadly and is more widespread.

The memory of SARS is influencing the sense of fear people have. In this case, China seems to be doing better with COVID-19 than with SARS. They mapped the disease pathway within two weeks and have done a better job with communication.

Now declared a public health emergency in the U.S., what does that mean for our hospitals and healthcare facilities?

The U.S. has a much different healthcare system than in China, with more stringent building codes that are effective in stemming the spread of airborne infectious disease. The CDC does an excellent job coordinating the nationwide response. Hospitals in the U.S. are well prepared for this. In fact, this year’s strain of influenza is a bigger concern than COVID-19.

However, non-healthcare facilities where there are large gatherings or airports are not prepared to deal with holding a potentially infected person, and they need to have trained staff who can evaluate and safely hold a person until they can be transferred to a healthcare facility for evaluation

How can healthcare facilities be prepared for patients to present with COVID-19? Are we prepared for a widespread outbreak in the U.S.?

Existing building codes mandate protections that guard against an outbreak like this in a hospital setting. When a patient presents in a U.S. emergency department, they walk into a negative-air-pressure waiting space with air exhausted to the outside. As soon as they enter, they are triaged. And if they present with a disease like COVID-19 or the flu, they are immediately identified as infectious and taken to an isolation room. From there, they are tested. And if further isolation is needed, hospitals have that capability.

So far, facilities in the U.S. are treating COVID-19 patients just like flu patients. It’s important that caregivers follow personal protective equipment (PPE) protocol. With COVID-19, the PPE will be similar to that used for the flu or tuberculosis.

How serious do you think the situation is, as it’s progressed in the U.S. in recent days?

According to the California Department of Public Health, while imported cases of COVID-19 have been detected in the U.S., there is no evidence of sustained person-to-person transmissions of the virus. On Jan. 31, Health and Human Services Secretary Alex M. Azar II declared a public health emergency in the U.S. to aid the nation’s healthcare community in responding to the virus. While the CDC maintains that the potential public health threat posed by COVID-19 is high, the immediate health risk for the general public in the U.S. is considered low at this time.

In fact, 80 percent of those contracting Covid-19 don’t require special treatment. The issues have been mostly with those who are already compromised. Not sure what this means long-term, but certainly our bodies are capable of defeating it on our own, in the right circumstances. Our overall societal lack of proper hygiene—hand washing, covering your cough, and avoiding nose picking and eye-rubbing—appear to be the biggest reasons for continued spread.

In meeting with the CDC, there is a concern that U.S. facilities don’t have enough N95 respirators to accommodate staff and/or patients. Academic medical centers are being approved to develop and use their own testing procedures, which will provide better access to testing. Federal officials say nearly 1 million could be tested this week.

If necessary, how are biocontainment/special pathogen units designed to handle this type of virus?

There’s still not a consensus on whether an SPU will be activated for Covid-19 patients, and that’s really a medical decision that I can’t comment on. In the past, SPUs have been activated for highly infectious disease like Ebola, which takes 21 days to run its course and is usually fatal. Our understanding of Covid-19 so far is that patients recover if treated, so we don’t know if an SPU is necessary.

An SPU is like an ICU on steroids. Nurses have to wear protective gear and breathing machines. Materials flow in a single direction, from clean to dirty, and nothing leaves the unit until it has been sterilized. In contrast, standard ICU and isolation rooms have two-way flow with risk of cross-contamination.

SPUs are designed to isolate the patient and protect the safety of caregivers, which starts the moment the patient arrives at the hospital. In planning, we aim to prevent future errors by working with doctors and nursing staff to understand the flow of caring for the patient and the flow of materials into and out of the unit. The goal is to create a unidirectional flow for caregivers and materials, eliminating the chance of infecting a clean room or space.

One of the lessons we learned from our site visits was to color code the doors and floors. Green means you can come and go through this door, yellow means there are restrictions to going through, and red means do not enter. Another lesson was to be sure we added autoclaves to sterilize any infected material leaving the unit. The unit is a long way from the sterilizers in the loading dock, and staff cannot safely transport infected material through the rest of the hospital without it first being sterilized.

SPUs require a dedicated mechanical system that is separate from the main hospital system. Patient rooms need to cleanable with harsh chemicals without damage to the finishes. (The CDC has recommended procedures for cleaning.)

Also, patients can be isolated for up to a month until CDC determines the person is ready and safe to leave, so the patient rooms need to balance safety with comfort. For example, the rooms need to allow clinical staff to have constant sight of the patient while he/she is very ill but offer some privacy while the patient is recovering. They need to be cleanable but not void of interior design features. As the patient heals, they will want to communicate with loved ones without leaving or having visitors. Communications technology has to be integrated into the unit design to allow patients to skype or otherwise video chat with family.

How did the hospital in Wuhan get built so fast? Would that ever happen here in the U.S.?

The U.S. probably doesn’t have the capacity to build an instant facility like the one in Wuhan, but it’s largely a moot point because we wouldn’t want to.

The facility built in Wuhan would not meet the definition of a hospital in the U.S. It doesn’t comply with the codes and regulations we have in place to keep patients and caregivers safe. It’s a series of modular buildings connected to isolate potentially infectious patients from the general population, but they aren’t isolated from each other. They’re kept in large mass quarantines, very similar in many ways to a “Nightingale hospital ward” except that the cross ventilation in a Nightingale hospital (replaced in modern hospitals with specific air changes by the HVAC system) is not apparent in what I’ve seen in the Wuhan facility.

U.S. federal agencies have emergency response teams equipped to build instant tent cities that would do a better job of isolating and treating patients. These types of temporary modular units were and are being used in Africa to fight Ebola. They have isolation rooms, anterooms, special showers, and storage space for PPE, and are capable of treating hundreds of patients.

L.A. County, for example, has a complete response system in place—mobile vans that can be quickly rolled out and set up in response to a community health crisis like this.

We keep hearing experts say to be more worried about the flu. What are best practices to keep in mind in terms of designing environments that can combat the spread of viruses, be it the flu or coronavirus? 

Hospitals need to evaluate the design and size of their isolation units in preparation for large outbreaks whether it is Ebola, MERS, another novel coronavirus, or the flu. During flu season, a hospital’s occupancy rate can peak over 100 percent. This is without considering an additional virus like Covid-19 infecting people in the U.S. during flu season. There are not enough respiratory isolation rooms to accommodate a large influx of infectious patients, but each hospital does have an emergency response plan in case of a large number of new patients.

In the future, hospitals may want to reevaluate their isolation ICU unit designs to allow for acuity-adaptive rooms capable of handling higher acuity patients when the need arrives. Acuity-adaptive rooms have all the infrastructure necessary to switch from a standard med/surg room to an isolation ICU room, but spend most of their lives as lower-acuity rooms. The materials in acuity-adaptive rooms are upgraded for cleanability; they may have additional treatment lights; the ceiling design is different; there are medical gases and storage space for specialized equipment and access to PPE.

Hospitals may also want to consider changing the overall layout of future ICU units to fall more in line with the design of an SPU. This would mean changing how materials and staff enter and exit the unit to create a unidirectional flow. They would want to create more visualization of patients and put additional technology in the rooms. Anterooms would have to be placed at the entrance of units to create an air block, and you would need sterilization capabilities at the exit to sterilize soiled materials. Finishes would be different, too, capable of handling harsher cleaning agents.

For more coverage from Healthcare Design, including on design solutions delivered to treat Ebola patients, search the archive for keywords “biocontainment” and/or “infection control.”