During the pandemic, hospital and healthcare administrators have been forced to respond to catastrophic conditions. Many have done so by adapting medical facilities in ways that have saved lives against the odds. Often, this has required them to rethink their systems and how they operate. These changes—sometimes physical, sometimes operational—have been crucial in the fight to save people suffering from COVID-19. And some of these changes may be here to stay.
Mount Sinai Hospital in New York City, one of the oldest and largest hospitals in the country, is an important test case in how hospitals can adapt in both the short term and long term to the changes COVID-19 has wrought. From efforts to conduct patient care in homes to hospital ward design tweaks that keep patients and caregivers safe, what’s being tested now could lay the groundwork for how hospitals care for the sick in the post-pandemic era.
COVID-19-ready in three weeks
Doctors at Mount Sinai knew early on they had to adapt. “When the surge was coming toward New York, we were just making rounds and we realized that the capacity for our existing spaces within a large urban hospital was not set up to meet the demands of social distancing or even air flow,” says Dr. John Bucuvalas, chief of hepatology at Mount Sinai. Hallways were bottlenecked with staff and equipment. Patient rooms were not properly ventilated. Staff was struggling to find adequate space to put on their personal protective equipment. “All kinds of things had to be modified in order to keep the providers safe,” Bucuvalas says.
Realizing this was more than just a question of rearranging hospital beds, Bucuvalas and a colleague reached out to MASS Design Group, a nonprofit architecture and design collective focused on architecture that promotes justice and human dignity. Much of the firm’s work has focused on healthcare spaces in places like Rwanda and South Africa, where infectious diseases present major design challenges. This experience gave the firm something of a head start in understanding how hospitals in the United States should respond to surging caseloads. In partnership with Ariadne Labs, a center for health systems innovation at Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health, MASS Design Group launched an effort to analyze the hospital’s spatial constraints. “We all mobilized immediately because I think we felt a great sense of responsibility and urgency to do what we could do as designers in this effort,” says Amie Shao, a principal at MASS Design Group.
Within days, Shao and her colleagues had mapped out a proposed plan to study and respond to the hospital’s changing conditions. Using GoPro cameras strapped on their heads, healthcare staff gave the designers a video walkthrough of the main spaces within the hospital that were dealing with COVID-19 cases to show how they were adapting to the surge. Because the main units being used to treat the virus are older buildings, their hallways are narrower than those in modern facilities, which exacerbated a lot of the challenges in dealing with an infectious disease. To reduce staff exposure to infected patients, most monitoring equipment had been brought out into the hallways. “So in addition to all these people, you have all this equipment trying to vie for space in the interest of patient and care provider safety,” says Ashley Marsh, senior architect at MASS Design Group.
After getting a better understanding of the constraints, the designers outlined some steps the hospital was taking to respond quickly. New walls and doors of transparent plastic sheeting were added to previously open ICU bays, allowing easier visual access to patients without the need to walk into infected rooms. And the rooms themselves were able to be easily converted to improve ventilation. Through the addition of hundreds of new large HEPA filter machines, 260 existing patient rooms were converted into negative pressure isolation rooms that prevent airborne diseases from leaving the room when the door is opened. A 100-bed unit for patients moving out of intensive care units was built in the hospital’s atrium, and a temporary tent-based outdoor facility with 68 beds. Other changes were low-tech. Color-coded paint was added to rooms to help staff quickly understand the risk threshold of the patient inside, and colored tape on floors and near doors provided further visual cues about risk areas and clean zones.
“We went from nothing to getting the project done in like three weeks,” Bucuvalas says.
Temporary changes that could become permanent
What worked well during the surge will also work well during less extreme circumstances, and many of the design changes are actually much needed improvements in how bulky medical equipment is corralled and where in shared spaces like hallways potentially contaminated PPE can be safely disposed. Many of the spatial questions raised by the surge of COVID-19 cases are also relevant to the hospital’s functioning in more normal conditions. “How do we support the enterprise, ensure that we have adequate, safe care and make sure that our staff are safe within the existing system that we have. That’s the challenge,” Bucuvalas says.
The design interventions are accelerating change that has been coming to hospitals, Bucuvalas says, and he expects things like the improved visual communication and color-coding of spaces to be integrated into the way hospital units work. And though negative pressure rooms aren’t required for every situation, the hospital now has the capacity to implement them as needed. Should another outbreak of such a highly infectious virus occur, the hospital will be ready.
Looking further ahead: hospitals at home
The pandemic’s impacts are expected to have significant effects on the operation of hospitals in the future—for healthcare providers but also for patients who are now much more hesitant to walk into a hospital. “I think the big shift is an attitudinal shift by patients. They don’t want to come to a hospital anymore,” says Dr. Bruce Leff, a geriatrician and faculty member at the Johns Hopkins University School of Medicine. “It’s hard for me to get my patients to come back and see me in my physical clinic.” Patients tell him they don’t mind having a visit over the phone if it means not having to spend half a day driving to the hospital, parking, waiting in a room before an appointment, and then driving back home, all for 20 minutes face-to-face with a doctor. “And I think that’s actually going to drive a lot of change in care,” Leff says.
It’s already pushing more interest in the emerging concept known as “hospital at home,” in which many types of care are conducted by doctors or nurses in patients’ homes instead of in the traditional hospital setting. Leff was an early evangelist of this approach, running clinical trials back in the ’90s, but it’s been slow to take off in the United States, where healthcare financing norms can make it hard for hospitals to get paid to provide such services.
But new payment models are emerging that allow Medicare reimbursements to hospitals for some off-site care, and the pandemic-induced reluctance to go to the hospital has led many more hospitals to give the idea another look. “We’re still in what I would call an early-adopter phase of hospital at home,” Leff says. “But I would say in the six months before COVID there was just a lot more inbound unsolicited calls coming to me about hospital at home. And then since COVID hit, it’s been a bit off the charts.”
Dr. Linda DeCherrie has been running the hospital-at-home program at Mount Sinai since starting a pilot program there in 2014. She says the impacts of the pandemic on the hospital business will lead more hospitals to rethink how and where they provide care.
During the pandemic, many hospitals saw non-COVID-19-related visits fall significantly. The drop-off in procedures like elective surgeries has led to revenue pains for hospitals. It has also led to space going unused. “Beds open is wasted real estate for them,” she says. Entire floors have to be staffed even if there’s only a single patient in a single room. In terms of costs, providing that one patient’s care at home may start to make more sense. She says hospital executives should look at how moving more services outside the hospital setting can allow that newly unused space to find a new purpose.
“They have to really think about what is the goal of this kind of a program for them. One may be they really want to offer more of something. Now they’re going to attract a new surgeon to their hospital or they want to have more of an oncology floor,” she says. “So if we can open up this space for those new conditions, that’s great for a hospital.”
An opportunity for new ideas
The pandemic may be a kickstarter for a lot of these forward-looking ideas. MASS Design Group has seen huge demand for its adaptation approaches. The firm has taken the methodology it used to identify design solutions for Mount Sinai and applied it to other spaces, including senior housing, restaurants, museums, schools, and other health facilities. With their head-strapped GoPro camera setup, they’ll be collecting data at the University of California San Francisco’s medical center next week. Some may just be trying to get through this difficult period, but many hospital systems, like Mount Sinai, will be using these pandemic-related design changes and adaptations to rethink how they operate in the long term.
“In two months more change happened than in the last 15 or 20 years,” says Leff. “As COVID rolls through, they’re trying to get back to the status quo ante because that’s how they made their money. But I do think some systems are going to want to push forward and do things differently.”