The New Normal of Architecture: The Future of Hospital Design in a Post-Pandemic World

by Tony McReynolds

MELISSA MAGNUSON, DVM, HAD A BAD FEELING ABOUT COVID-19.

Magnuson owns AAHA-accredited Canobie Lake Veterinary Hospital in Windham, New Hampshire, where her alarm bells starting going off after meeting a client.

It was early last March, a few weeks before lockdowns, curbside service, and working from home became the new normal. A woman brought her sick dog to the hospital for treatment. Both the receptionist who checked them in and the technician who took them back to an exam room thought something about her was off.

The technician tracked Magnuson down and told her about the woman and her red-rimmed eyes, apparent exhaustion, and general end-of-her-rope impatience. And about her nonstop coughing.

“She looks really, really ill,” the tech said.

So Magnuson donned an N95 mask and entered the exam room. The patient looked every bit as bad as advertised. Their conversation went something like this:

Magnuson: “You’re sick. You should be at home.”

Client: “My dog is sick. You need to take care of her.”

Magnuson: “I’ll take care of your dog, but you’re going to put on a mask first.”

Client: “I’m not wearing a mask. And you will look after my dog.”

Magnuson: “If you don’t put on a mask, you will leave.”

Client: “I will not put on a mask and I will not leave, and you will take care of my dog.”

Magnuson: “If you do not leave, I will call the police.”

At that point, the woman agreed to don a mask.

“I told her I was going to stand outside in the hall and take the information about her dog through the closed door,” Magnuson said. “If I had to go attend to something else, I had someone in a mask stand guard outside the door. She wasn’t allowed to leave the room. She wasn’t allowed to go to the bathroom.”

Magnuson said she didn’t know what the woman was sick with, “but it sure looked like COVID to me.” It was more than a guess. Magnuson had a background in infectious disease and, before getting her DVM, worked in vaccine development.

The dog was a West Highland terrier with a skin issue that turned out to be a complication arising from previously diagnosed Cushing’s disease. As soon as the appointment was over and the woman left via the back door—to keep her from coming in contact with any other clients or staff—Magnuson had masked and gloved staffers disinfect the room and anything else in the hospital the woman might have come in contact with.
“The next day,” said Magnuson, “we went curbside.”

She also instituted strict safety protocols for staff and clients. Her staff thought she’d gone insane, “completely over the top.” But within a month, the pandemic was on, and across the country, other hospitals were doing the same.

A Pandemic-Proof Hospital by Happenstance

Magnuson’s previous work with infectious disease meant the hospital had already been close to pandemic-proof. Just a little over a year before that client walked through the door with her terrier, Magnuson had worked in collaboration with architect Heather Lewis, AIA, NCARB, to design a safe hospital from the ground up. Lewis is a partner at Animal Arts, a Boulder, Colorado–based architecture firm that specializes in designing veterinary hospitals and animal shelters.

Magnuson and Lewis decided on details that Lewis says will become standard across the industry in post-COVID hospital design. The lighting and the sinks have hands-free motion sensors, and the doors either push open or have lever handles that are easily openable with an elbow. Once the pandemic got into full swing, Magnuson said, “I found out we had a hospital that was really great in a pandemic, kind of by mistake.”

Lewis says veterinary practices had to pivot fast last spring. “The transition to offering curbside service taught us two important lessons: One was how to temporarily pandemic-proof a hospital.”

The other was that there’s always a chance another pandemic will strike.

As a result, Lewis says, Animal Arts’ clients are clamoring for ideas on how to prepare their practices to safely weather a future infectious disease outbreak. Those ideas include building a completely new hospital or retrofitting their current hospital, incorporating some of the details used in Magnuson’s hospital. The design firm has been taking note of what’s been working for hospitals this year and looking for ways to apply those lessons in ways that will pandemic-proof veterinary hospitals in case the unthinkable happens again.

Making use of indoor/outdoor space is an idea that works well in regions where the weather will accommodate it. The transition to curbside got clients and staff used to doing check-ins and pickups in the hospital parking lot, so, Lewis says, it’s not a big leap to start using indoor/outdoor exam rooms. The client can then be present during the exam while maintaining social distance, and it’s great anytime for fearful or anxious dogs.

Animal Arts works with Fear Free to design hospitals to their specifications, and indoor/outdoor exam rooms are a staple of Fear Free design. They’re also good for euthanasia. It’s a good example of a pandemic-proof design element that adds greater flexibility and functionality to a hospital in general.

The same goes for outdoor waiting areas, which make social distancing easier and can supplement the lobby during nonpandemic times. The outside can also be a more pleasant place to wait. Think porches, Lewis says.

Another small but significant detail we’ll see more of in the future is sinks. “People have gotten used to washing their hands,” Lewis said. “We’ll likely see more sinks in exam rooms again.”

Flexibility

Going curbside taught us many things, but the most significant may be the importance of being flexible.

The key element to COVID-inspired hospital design is flexibility, says Lewis. Especially when it comes to designing multipurpose workspaces, or flex spaces, as Lewis calls them, inside the hospital.

Take the front-desk area. More space means receptionists can easily socially distance, but if your hospital can’t spare the extra square footage, a wheeled desk can easily accommodate social distancing between clients and staff.

Wheels help in treatment areas, too. “You actually don’t need to have more space,” Lewis said. “You can simply put one or more of your workstations on wheels.” To maintain safe distance, just roll the mobile station to another part of the room.

Also consider either repurposing or adding an oversize examination room that’s close to the treatment area. “When there’s no pandemic, you use it as a regular exam room. When there’s a pandemic and you’ve had to lock your clients out, you can use it as an extra treatment space.”

Lewis says this is a great solution for practices that have “a million clients dropping off pets for surgery at eight in the morning and picking them up again at five in the evening but have nothing going on at 11:30 a.m. This flex exam space allows you to do more procedures during that dead time.” Dentals, for example, with a dental treatment station on—what else?—wheels.

Pandemic-friendly flex space is also budget friendly. So it’s a good way to keep construction costs down while redesigning hospitals with future pandemics in mind.

Mud Rooms and More

When more employees work from home, especially support staff, it frees up hospital space for virtual care stations. Lewis says Animal Arts is designing spaces that include rooms dedicated to telemedicine. “[Teams] can actually do more work and generate more revenue in the same square footage. That’s pretty awesome!”

Many hospitals have rigged up a mud room ad hoc, anywhere they could find the space. Lewis recommends locating a mud room in a space dedicated to entry and exit, which “gives you a place to store boots, winter clothes, and log into a computer during normal times. It also allows for safe entry and temperature checks in future pandemics.” Animal Arts is now recommending mud rooms as a standard design element.

An exam room specifically designed as an isolation room with air exhausted to the outside for pets and clients who may have an infectious disease is also a smart idea. In normal times, it’s simply another exam room.

Where to find all this extra space? Lewis advocates eliminating a children’s play area, which is tough to keep clean and almost impossible for social distancing. “Kids are pretty germy and they touch all kinds of things,” she said. And hospital staff certainly don’t want to clean things those kids touch. “Play areas?” Lewis said. “I think they’re dead.”

HVAC Is Its Own Thing

Hospital heating and cooling systems are a little more complicated than putting a desk on wheels. We know that COVID is spread through respiratory droplets sprayed into the air when people sneeze, cough, talk, or even sing. Those droplets can linger in the air, like dust or a fine mist, for much longer that previously suspected in the form of aerosols, which are droplets smaller than five microns (a micron is equal to one-millionth of a meter).

The possibility that COVID is aerosolized means virus particles can float in the air and get sucked into ventilation systems, where they can be recirculated through heating, ventilation, and air conditioning (HVAC) systems and theoretically contaminate whole buildings.

The US Centers for Disease Control and Prevention confirmed in October that COVID can be spread through aerosolization, and hospital administrators are almost universally concerned about ventilation.

Mechanical engineer Carrie Pepperdine says most animal hospitals already have decent HVAC systems due to concerns about containing smells and other airborne pathogens that come with the practice of veterinary healthcare. So existing hospitals are probably in a good position.

Pepperdine designs HVAC and plumbing systems for 20/20 Engineering, a Louisville, Colorado, mechanical and plumbing engineering firm that partners with Animal Arts in the design of their clients’ ventilation systems in accordance with guidelines from the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE).

The kind of filters you use makes a big difference, too.

Minimum Efficiency Reporting Value (MERV) is a system used to evaluate the efficiency of an air filter based on how effective it is at catching particles of varying sizes. “MERV-7 is the standard minimum filtration,” Pepperdine said. “ASHRAE leans more toward going with a MERV-13 filter in conjunction with increasing the ventilation rate.”

That means hospitals might want to look into upgrading their filters. “MERV-13 filters are around 90% efficient at removing contaminants,” said Jerry Oglesbee, an HVAC expert at 20/20. He compares that to an N95 mask, which is 95% efficient.

High-efficiency particulate air (HEPA) filters are the gold standard for air filtration: They are 99.97% effective at removing dust, pollen, mold, bacteria, and any airborne pathogens 0.3 microns in diameter.

That’s pretty good, but possibly not good enough: “If [COVID] is airborne, it’s most likely coming through at a slightly smaller size,” said Pepperdine. But like much of the science surrounding COVID, “they don’t know for sure.”

The downside to HEPA filtration? “HEPA filters are way more expensive,” Oglesbee said. Plus, it requires more power to run the fans, so there’s an additional energy cost. Because of the combined costs, 20/20 usually only specifies the use of HEPA filters in surgery suites and operating rooms at specialty hospitals.

Another consideration is how long the virus lives on different surfaces, on which there’s currently no clear consensus. Oglesbee’s frustration is apparent: “That’s been all over the map [over] the past few months.” He said even if COVID can’t get through the HEPA filtration, “that doesn’t mean [the HEPA filter] isn’t itself a contaminated surface that needs attention.”

In the meantime, there are low-cost precautions that hospitals can take.
Pepperdine says one such option would be to change out or upgrade air filters. Another is to make sure the outside air dampers are set to optimize their ventilation rate. “Most likely, hospitals already have this capability in place,” she added, but she recommends hiring HVAC professionals to do it.

The good news is, those are precautions. Pepperdine says that if your HVAC system is up to date and regularly maintained, you probably don’t have to worry—what you have in place is probably fine.

But if you’re still worried about aerosolization and you feel the need to do something, Pepperdine says the easiest thing you can do is run your exhaust fans and air conditioning all the time, even when no one’s there.

Lewis says air treatment systems that utilize ultraviolet (UV) light to kill viruses are another option for hospitals. “These combine UV germicidal treatment as well as some ionization of the air,” Lewis said. “What’s cool about these is that they can either be integrated with the HVAC system, or purchased as just a room air cleaner.” But using one, she added, is like opening a window. It’s a stop-gap measure, though a cost-effective one for hospitals on a budget. “If you can’t design everything right from the ground up, putting in a standalone air treatment unit is not a bad idea.”

Pandemic-Proofing Existing Hospitals

Retrofitting to pandemic-proof your existing animal hospital is also an option.

Birmingham, Alabama–based Southern Veterinary Partners (SVP), a network of 165 regional veterinary hospitals, isn’t doing any ground-up construction at present.

Neal NeSmith, CCIM, SVP’s real estate development lead, said, “We’re working with Animal Arts on renovation of our existing hospitals.” That means working with the spaces they already have to identify opportunities to incorporate social distancing.

Like many hospitals, SVP hospitals are still mostly curbside. NeSmith says the goal going forward, once clients are admitted back inside, is to limit the amount of time they spend in the building.

Lewis says most of her work with SVP involves working to provide them with more examination rooms. As far as pandemic-proofing an existing hospital, Lewis said, “The more clients you can move into examination rooms, the fewer you have clogging up the lobby. Having more exam rooms gives hospitals much more flexibility.”

NeSmith says that largely involves identifying unused or underused spaces, such as storage rooms, that are suitable for retrofitting as exam rooms and where clients can be isolated once they’re allowed back into the building.

William Ratterree, DVM, DACVIM, DACVR, is chief executive officer of Fetch Specialty & Cancer Veterinary Centers, a thriving, family-owned group of three emergency and specialty hospitals in southwest Florida. He’s working with Animal Arts on a couple of ground-up construction projects that will incorporate many of the new changes inspired by COVID.

Ratterree says the biggest changes revolve around space. There’s going to be a lot more of it.

“The exam rooms will be bigger to allow for social distancing, so everyone can be six feet apart,” Ratterree said. “We’re converting all the doors to automatic doors to decrease touchpoints. Reception areas will be larger to accommodate employees sitting at different stations.”

Several clients will be able to work with several client service representatives at the same time, while all are socially distanced. It will work a bit like a bank lobby, where customers interact with different tellers. He calls it an “open-field” lobby, with plenty of room for both clients and staff to spread out safely.

Ratterree is also working with Animal Arts to retrofit his current hospitals to accommodate these changes where possible. He says his most important goal in both the retrofitting and the new construction is to protect the hospital’s most important resource: “the staff.”

Melissa Magnuson can relate. Speaking of the client who wouldn’t leave, Magnuson said, “Her position was, ‘I don’t care how sick I am, I’m going to get my dog taken care of.’ My position was, ‘I need to take care of your dog, but I also need to take care of my staff and you’re not going to infect them.’”

But whether you’re talking retrofitting a hospital to pandemic-proof it from COVID or building a pandemic-proof hospital from the ground up to prepare for future viruses, Ratterree says one thing’s certain. “Our old way of ushering clients in and out of our veterinary hospitals has changed.”

Probably forever.

Tony McReynolds is AAHA’s NEWStat editor.

 

Photo credits: ©AAHA/Robin Taylor, photo courtesy of Melissa Magnuson, photos by Tim Murphy, FotoImagery