In late January, the Javits Center in New York City hosted a jolly meet-and-greet with the show-stopping dogs of the American Kennel Club. Today, the same space is filled with 2,600 emergency beds where medical staff are treating patients with COVID-19.
Across the country, the story is the same. The U.S. Army Corp of Engineers (USACE), working under FEMA’s $1.6 billion budget, has spent the past few weeks scouting over 800 facilities to convert them into COVID-19 wards in response to bed shortages at hospitals. Some are closed hospitals that are being reopened. Others are empty hotels that are getting retrofitted for patient care. But the vast majority of wards are being constructed in what USACE classifies as “arenas,” including the McCormick Place in Chicago, the Music Center in Nashville, and the Michigan Expo Center.
These largely open ballrooms and convention centers are being converted to accommodate thousands of patients. Images of these facilities are grim. Hospital beds are side-by-side, with cloth dividers and 6 feet of distance between. There’s little privacy, let alone creature comforts. But arenas are more practical for acute care than they might appear—and they can be adapted in time to accommodate the peak loads of COVID-19 patients that public health officials are projecting, as the virus spikes across the country. “We don’t normally get more than two weeks of opportunity to build out [anything],” said George Lea, chief of military engineering at the U.S. Army Corps of Engineers, during a conference call this week.
These conversions are a portrait of the U.S. response to the COVID-19 crisis. As of earlier this week, the Javits Center had only filled 66 beds, not because New York City doesn’t need relief, but because of what’s been labeled a miscommunication between city hospitals and the federal government. China mobilized to build new hospitals in less than 10 days. Efforts here in the United States have been more piecemeal, and adapting existing buildings has been the fastest, most utilitarian approach. As crude as these makeshift hospitals may appear, government workers and experts say they’re our best option.
The system wasn’t built for this
There’s an old adage in architecture: You can’t build a church for Easter Sunday. The logic is simple: If you build something for peak capacity, you can’t afford to sustain it with day-to-day use.
It’s easy to blame the medical system for designing facilities without regard to the COVID-19 surge—or for not stocking up on ventilators and PPE—but the surge was beyond even the best estimates of experts in the industry. HKS is a major architecture firm specializing in hospitality and healthcare that’s currently leading the retrofit of the Michigan Expo Center. The firm also led a landmark study after September 11 about peak capacities in healthcare. Working with experts under a government grant, they spent years developing a 1,000-page report called ER One—essentially a playbook detailing how the emergency room of the future would need to change to accommodate an onslaught of patients from bioterrorism or a pandemic.
“In that study, the surge planning we were looking to accommodate was anywhere from four to six times the daily volumes for emergency departments,” says David Vincent, principal and director of health at HKS, who was involved with the study. “[COVID-19] goes way beyond four to six times the daily volumes. . . . No one is really thinking about an event that’s hundreds of thousands or millions of people. The scale of it just caught everybody off guard.”
A purpose-built hospital would be ideal. China used prefabricated components to piece together hospitals quickly in response to COVID-19. The U.S. manufacturing infrastructure has the technical capability to do so, too, but it would take us weeks to months, requiring a round-the-clock labor force.
As COVID-19 spread across the globe, HKS began modeling alternative care facilities, like how they might retrofit a hotel or school to accommodate the surge—no doubt, anticipating they would be called to work. Their baseline for care was simple: “Is it better than a tent?” says Jason Schroer, principal and director of health at HKS. “Honestly that’s where it all started. We began to see early ideas on mobilizing football stadiums, soccer fields, Central Park with meshes and tent structures. Those can be effective! But are there other solutions that can be better.”
Under orders from the president, FEMA only got involved with COVID-19 relief on March 19. USACE quickly developed a rubric for assessing existing structures for conversion into wards. To date, their 15,000 workers have acted quickly, having assessed over 820 structures, about half of which were arenas and half hotels. So far, a significant majority of properties that got the green light, however, are arenas. (The full list of properties is here, and it’s growing by the day.)
The popularity of arenas over hotels might be surprising. Hotels are, in many ways, a perfect place to house non-critical patients who can have private rooms with bathrooms alongside the doctors who are caring for them. Many hotels have food service and laundry facilities available onsite, too, which are both ideal criteria for supporting so many people. Furthermore, hotel operators with no customers are hungry for the FEMA grants, which can be structured to cover a complete renovation once the hotel is ready to reopen after the COVID-19 crisis.
“Our organization has a tremendous network of hotel owners, and a lot of them are closed and empty, and a lot of those owners might be very interested in stepping up and offering those buildings for healthcare workers and patient use,” said John Hogan, Marriott’s vice president of design and project management, in a recent meeting. Indeed, San Francisco, New York, and New Orleans have all repurposed hotels for healthcare workers and patient care.
Speed is the most important factor
But a major reason we’re seeing so many arenas is that arenas are often publicly owned, while negotiating with private companies and owners over hotels requires resources the government can’t spare. “It does save time and process when the government or state owns the facility, like the Javits Center in New York,” says USACE’s Lea. “We had days to complete the facility. We don’t have the luxury of time.”
The design of arenas is amenable to quick setups. After all, they have to be set up and dismantled for each new performance or sporting event. They have wide open spaces and hallways, which makes it easy to wheel in equipment. It’s also easier to set up when you only have one or two floors to work with; you waste less time waiting for elevators. (Meanwhile, hotel doorways aren’t even wide enough to squeeze in standard hospital beds.)
USACE has developed guidelines for converting spaces into wards, but they’re only guidelines. Meanwhile, stand-alone architects and construction groups actually oversee the technicalities of converting spaces. “Best practices get thrown out the window,” says Schroer, who describes a design process that involves quickly sketching layouts and patient flows onto floorplan PDFs and distributing those to a construction crew—a far cry from the detailed schematics they would normally be rendered for a healthcare project.
Big, shared rooms make a lot of sense
The expansive spaces of conference centers and ballrooms have other benefits. Pooling everyone into a large room means that it’s easier to share key equipment and highly trained staff—staff who aren’t required to touch doorknobs or extraneous surfaces with all the walls out of the way. “We think a lot about caregiver-to-patient ratios,” says Schroer. “That’s going to be one of the pinch points in any venue: How do you staff it, where do they come from? With large, open wards, you can be much more efficient in staffing.”
All that wide open space also makes it easier to design how people move about the space. Architects model pathways through which healthcare staff circulate. A key to any hospital is that the staff always moves one direction to check on patients, like a one-way street, which helps mitigate the spread of infection. Furthermore, patients are grouped by cohort—sicker patients are grouped together, which helps the staff manage and prioritize care.
But is it safe to have so many people breathing the same air in one room? It is certainly not ideal. The gold standard are the negative pressure rooms in hospitals, which can ensure that contaminated air never leaves a patient’s room by essentially turning the room into a giant vacuum cleaner that filters or ejects the dirty air outside. But experts we spoke with for this story suggested, second to negative pressure, arenas are our best option.
It’s not practical to scale negative pressure rooms solely because of time and effort, but large venues have HVAC systems that are built to suck in fresh air and blow it onto crowds, so they aren’t breathing in a stagnant soup—which is the next best option for diluting pathogens in the air. There are limits to what these HVAC systems can do: Air from the outside still has to be heated or cooled and humidified. But especially in temperate climates, these systems can pump in significant amounts of fresh air.
We do need to consider hotels and schools
Though arenas have become the de facto venues for COVID-19 wards in the past few weeks, they aren’t alone. Experts are still considering other vacant building types.
Schools, for instance, are promising. They have big spaces, like gyms, that can be used for acute care, and they have classrooms that can be used for lower-risk patients. Schools also have cafeterias onsite, and especially in rural areas, a high school could be the single largest building to accommodate patients for miles around.
Ultimately, plans are likely to change, and designs may shift in the coming weeks, as everyone involved admits that these makeshift wards are not perfect. “We’re trying to take lessons learned from Detroit, and [decide] if they have to do something the same or different in Arizona, or New Orleans, or California,” says Schroer. But for now, getting facilities built as quickly as possible is the USACE’s main priority. Then it’s up to the government to get patients in there and treated.
If for some reason you or your organization has a large property that you believe could help with the COVID-19 pandemic, Lea’s best advice is this: “Reach out directly to local county and state healthcare professionals, and make your opportunities known.”