How to Make Ambulatory Care Centers More Adaptable

Six Ways to Prepare for the Next Pandemic by Reconsidering Healthcare Design Guidelines

May 26, 2020

Senior Associate, NBBJ

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Editor’s note: Our healthcare clients are on the front lines of the coronavirus crisis. We seek to support them as they courageously care for the sick. So we’re posting design ideas based on work with them, in the hope that we can contribute from our base of expertise to help combat the epidemic. From all of us at NBBJ to the many doctors, nurses and support staff in hospitals and clinics, thank you from the bottom of our hearts.

Editor’s Note: This post was co-authored by Noelia Bitar and Paula Buick.

 

The number of outpatient centers has increased dramatically in recent years, but as scheduled appointments were canceled during the coronavirus, this valuable real estate stood empty. Because ambulatory centers already have basic healthcare infrastructure in place, they potentially could flex to accommodate an inpatient surge; however, many of these facilities were designed to meet only the minimum requirements of current codes — like the FGI Guidelines, which establishes national standards for the design and construction of healthcare facilities — and as a result their ability to be adapted for inpatient care is limited.

As we think about building new ambulatory care centers, a few design considerations, above and beyond code minimums, could make it easier for these facilities to flex to meet future inpatient surges or post-acute care needs. Given funding constraints, it may be challenging to incorporate all of these features into every ambulatory care center; however, these are some of the options a health system might consider:

1. Build public spaces that allow for easy conversions. If utilized during a surge event, ambulatory care centers would likely transition from opening only during a set number of hours each day to a 24/7 service, which, because inpatient care requires more staff than outpatient, would require an overall increase in staff on all shifts. This increase would require additional support areas, which will impact the design of public spaces. These spaces should be designed so lobbies can be converted for triage (screening, testing, queuing, etc.) and patient waiting areas converted into “team work areas” where care team stations, staff amenities (lockers, lounges) and clinical support services can be located outside of patient areas that might be required to be isolated. The code currently requires waiting areas to have a ratio of 1.5 to 2 chairs per patient care room, but it does not specify a square footage per chair; we find that 25 square feet per chair is a good standard for providing additional future space flexibility in waiting areas.

2. Design exam rooms to flex beyond outpatient care needs. The minimum clear floor area required for patient exam rooms per the guidelines is 80sf, but as we design for future flexibility, we could see a shift to allow for stretchers to be used in these rooms. Taking into account the appropriate clearances that might be required, 120 square feet is a more appropriate minimum, and sometimes 140 square feet for multidisciplinary-based team care.

Medical gases such as oxygen and vacuum could be included in at least some exam rooms, even though the code does not require any medical gases in a standard exam room. The addition of medical gases in general ambulatory centers will allow for these rooms to flex when needed.

Because telehealth is important not only for expanding access to care but also for helping to reduce exposure to contagion for both patients and staff, it would be beneficial to integrate technology and design that supports telehealth or teleconsults into more exam rooms. While the outpatient guidelines offer dedicated spaces where telemedicine could take place, such as a bay, cubicle or room, including it in every exam room would provide additional support. Consider elements such as:

  • Monitors with fixed cameras or mobile carts for telehealth and remote consults to be able to remotely view and communicate with patients
  • Communication tools, including “nurse-call” that is voice-activated (the current code does not require nurse call devices in exam rooms)
  • Television for patient distraction and education

Larger 4′ (or 48″) door openings could be the new norm for the exam room and all patient areas — even though door openings serving occupiable spaces are usually a minimum clear width of 34″, or 41.5″ where stretchers are used, and 4′-door openings are typically only required in the path of travel to public areas and in areas where care will be provided for patients of size. Using sliding doors or double-leafed doors could accommodate a wider opening without impacting the design of the room.

Even though an exam room, by code, requires privacy for patient consultation, integrating a transparent material like a narrow light or half window with integral blinds would allow it to flex into an observation room, which by code requires patient visibility. Sliding glass doors with a translucent film could be used to maintain privacy while providing light into the corridors during normal exam-room use, but the film could easily be removed and allow for transparent glass, if the room needed to flex for observation.

3. Plan for an isolation zone within outpatient care areas. An entire floor or section of an ambulatory care floor could be designed to become a negative pressure area. Rooms would need to identified for transforming into donning/doffing PPEs, and with a one-way entry and exit flow.

Similarly, while Airborne Infection Isolation (AII) exam rooms are only required in specific programmatic ambulatory needs, having the option to accommodate a patient who has screened positive for an airborne infection may be advantageous in the surge response plan. A minimum number of AII exam rooms could be required, along with an adjacent room or space to serve as an ante room or vestibule. And don’t forget that patient isolation can function at multiple scales.

4. Expand corridor widths to allow multiple flows. Although outpatient guidelines only require 6′ corridors in areas where there is use for stretcher transport, if corridor widths were required to be a minimum of 6′ throughout, they could accommodate stretchers and other circulation needs, and support PPE carts outside rooms, EVS cart parking, patient transportation etc.

5. Choose the soiled workroom over the soiled holding room. Most outpatient general facilities only require soiled holding rooms in exam areas, as they are only used for temporary storage of soiled materials and supplies — as opposed to more intensive soiled workrooms, which include additional plumbing and space in which staff can work. However, choosing to include the soiled workroom in outpatient settings will also allow for cleaning or disposal of soiled items with the multiple sinks required by code for inpatient care.

6. Add redundancy in infrastructure. Including additional electrical power in public areas like waiting rooms and exam rooms makes it possible to support additional equipment loads such as physiological monitoring, mobile diagnostic equipment, emergency power and more. Likewise, HVAC systems ideally would be flexible enough to accommodate 24×7 patient care, additional cooling for increased staffing, thermostats in each exam room or the modest increase in air changes per hour — from 4 to 6 — required by code for inpatient settings. Most general ambulatory centers like medical office buildings do not require these types of redundancy per code requirements.

Many of these features will entail additional costs. However, there are also significant costs associated with leaving an ambulatory care space idle because it is unable to meet unexpected care needs like the Covid-19 pandemic. Some additional upfront investment may be necessary but doing so will ensure that these centers will be ready to flex when the next emergency arises.

 

How are you and your healthcare organization dealing with the coronavirus? We’d like to hear from you. Drop us a line at socialmedia@nbbj.com.

Banner image courtesy Sean Airhart.

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Getting Hospitals Back on Track: Safely Bringing Healthcare Back Online

How to Prepare Our Hospitals to Balance COVID and Non-COVID Care

May 21, 2020

Healthcare Partner, NBBJ

Editor’s note: Our healthcare clients are on the front lines of the coronavirus crisis. We seek to support them as they courageously care for the sick. So we’re posting design ideas based on work with them, in the hope that we can contribute from our base of expertise to help combat the epidemic. From all of us at NBBJ to the many doctors, nurses and support staff in hospitals and clinics, thank you from the bottom of our hearts.

This post initially appeared on Forbes. It was co-authored by Ryan Hullinger and Sarah Markovitz.

 

Since the middle of March, nearly all elective surgeries and medical procedures in America were postponed to create capacity for the first wave of Covid-19 patients. While the curve has started to flatten and many facilities are reactivating their procedural platforms, there is still hesitation in patients seeking in-person care for fear of inadvertently exposing themselves to the virus. As a result, many patients with both chronic and acute conditions are putting off necessary health maintenance and avoiding trips to the hospital.

For the healthcare industry, this is devastating both in terms of its impact on patient care and its bottom lines. Hospitals — especially non-profit hospitals — historically operate on extremely narrow financial margins. With so many departments sidelined, the average American hospital has seen an estimated average drop in operating revenue of 40 – 45%, resulting in significant furloughs. These actions take a huge emotional toll on staff, many of whom were bracing for battle only a month ago and are now suddenly without a job.

America can’t afford to continue putting its wider healthcare system on pause in the likely event of another patient surge in the summer or fall. So what solutions could help keep appointments and procedures on track? And how can we ensure that they are performed in a safe manner?

All entrances, lobbies and screening processes should look calm and well-organized to assure patients that the facility is in control of the situation and safety is the number one staff priority.

There are many design changes that can make this happen and many of them begin before patients set foot on hospital grounds. Hospitals should use their websites to present clear communications with patients so they are aware of the safety precautions and instructions for their arrival.

Inside the hospitals, there needs to be legible signage that communicates cleaning and disinfecting processes for the facility. For example, many hospitals have existing digital signage outside of rooms that previously communicated room occupancy. This can be repurposed to communicate cleaning frequency and efficacy. This can be as simple as something like “This room was cleaned three minutes ago and is ready for use.”

Thoughtfully planned wayfinding will be equally important. These need to demarcate separate pathways for those with and without Covid-19 symptoms entering the site, covering the patient journey from the parking to the entrance to the treatment areas. Wayfinding solutions could use unique colors and shapes – such as the color pink or a triangle shape – to help messages stand out.

Planning hospital flow for optimal safety

Accommodating coronavirus and non-coronavirus patients in the same hospital requires thoughtfully planned and clearly delineated processing and treatment zones. The Centers for Medicare & Medicaid Services recommends establishing distinct zones for each group. In the coronavirus care areas, symptomatic patients will be identified, screened and receive appropriate medical guidance and contract tracing efforts. Where possible, these areas should be physically separate from other hospital services — this could be a different building, a dedicated room/floor with its own entrance, or pop-up tents adjacent to the hospital.

For patients with Covid-19 who come for treatment of other issues and conditions, a bespoke multidisciplinary clinic can be set up to address their needs. For patients who have yet to be screened, administrators can work together to plan uni-directional flows throughout hospitals so those coming in and going out don’t cross paths with one another.

This will also require consideration for features like elevators to ensure they don’t become contamination zones — potentially by having designated staff operate them, reducing the number of persons allowed in at any given time, and identifying separate elevators for coronavirus and non-coronavirus patients.

Rethinking the waiting room

Balancing care for coronavirus and non-coronavirus patients in parallel may require rethinking the traditional waiting room entirely. Hospitals are designing new patient experience systems to alleviate patients’ anxiety by limiting the amount of time in the hospital outside of direct appointments and treatment.

After being screened for Covid-19 at a triage tent, patients can wait outside the hospital until they receive a text that their doctor is ready to see them, at which point they are taken straight into a treatment room to promptly be seen by their provider. By using mobile communication tools, these hospitals are decentralizing and streamlining the waiting room experience.

For the majority of Americans who access hospitals with their own vehicle, cars could become the new waiting room. For those living in more urban settings, hospitals can consider converting larger and more spacious rooms like cafeterias and conference rooms into waiting areas. This would allow for greater distance between patients waiting to be seen. Reconfiguring furniture for appropriate spacing, leaving signs on chairs and tables after they’ve been cleaned, and using markers to establish appropriate distancing for any lines are all immediately actionable solutions.

All of these considerations will change as PPE supplies, Covid-19 screening, antibody testing, and tracing programs continue to evolve. By closely aligning thoughtful and innovative hospital programming and operations with solutions that project a sense of safety and care, we can start to reconfigure our hospitals and healthcare facilities to operate within this new reality.

 

How are you and your healthcare organization dealing with the coronavirus? We’d like to hear from you. Drop us a line at socialmedia@nbbj.com.

Banner image courtesy Benjamin Benschneider.

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How to Design a Nightingale Hospital to Be Operational in One Month

Five Lessons in Rapid Hospital Construction

May 11, 2020

Partner, NBBJ

Editor’s note: Our healthcare clients are on the front lines of the coronavirus crisis. We seek to support them as they courageously care for the sick. So we’re posting design ideas based on work with them, in the hope that we can contribute from our base of expertise to help combat the epidemic. From all of us at NBBJ to the many doctors, nurses and support staff in hospitals and clinics, thank you from the bottom of our hearts.

 

To deal with a potential surge of inpatients due to COVID-19, many healthcare organisations around the world are constructing “Nightingale Hospitals,” named after the founder of modern nursing Florence Nightingale, in which patients are typically housed in open wards instead of private rooms.

Designing, building and commissioning these hospitals quickly is a major undertaking. But lessons learned from recent projects [download an infographic about the construction of one here] provide insight into how to deploy them elsewhere in the future. Here are five ideas to consider when developing a temporary field hospital:

Choose a simple structure: Because making quick decisions is imperative, opting for a prefabricated shell ensures a hospital can be quickly erected and demountable. For example, a spaceframe roof can be assembled at ground level with a hydraulics lift to put the roof into position. In some cases the shell can be erected in as little as five days.

Care for the caregivers: Provision of staff respite spaces is incredibly important during this stressful time. These facilities may include a staff lounge with views of the outdoors, a space for pause and reflection, as well as staff changing facilities and a dedicated staff entrance into the hospital. Space should also be furnished for changing into and out of PPE, with strategically placed PPE top-up facilities throughout the building.

Ensure patient privacy: Preserving dignity is important to patients, particularly at such a traumatic time and in such a large open space. Folding screens and fixed “wing walls” can create a sense of privacy that helps put patients at ease and enables them to recover faster.

Create a clear segregation of flows: Arranging the wards as 30-bedded units with a centrally placed nurse base and medication facility at the centre of each provides good views to patients. Placing clean and dirty utilities at opposite ends of each ward provides ease of access and segregation of flows.

Standardise for quick construction and easy navigation: Standardising bedheads for acute care, including oxygen provision but not invasive ventilation, is a good way to save time during construction and use.

When creating a Nightingale Hospital, all established ideas about designing healthcare environments need to be rethought. Solutions must be developed, first from principles and patient services to fire strategy and the coordination between the design teams, site teams and the client.

 

To learn more about how to construct a nightingale hospital, click here to download an infographic overview of a recent one in Jersey. 

 

How are you and your healthcare organisation dealing with the coronavirus? We’d like to hear from you. Drop us a line at socialmedia@nbbj.com.

 

 

 

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