Hospital architecture in times of crisis

Abstract

In times of crisis, such as public health emergency, military conflict or natural disaster, health systems face immense pressures. Large-scale crises continue to appear at irregular intervals and healthcare facilities should be prepared to react quickly and flexibly to the increased need for treatment and care. This paper aims to outline key concepts related to healthcare architecture during a mass-scale crisis, discuss challenges, and suggest solutions. Although the field lacks robust research evidence, lessons learned from past and ongoing events clearly indicate that advance planning is essential for effective crisis response. The crisis response has three guiding principles -adaptability, flexibility, and creativity. The interventions can focus on adapting existing healthcare facilities, building new units, and repurposing civil facilities for hospitals. A wide range of building typologies can be utilised, including modular containers, tents, lightweight structures, and repurposing civil buildings and public spaces. These interventions must be quick, economic, durable, and easily deployable. Temporary facilities must ensure an effective spatial platform for patients and staff, establish links with existing services, and consider post-crisis life of interventions. While these principles can be considered for any type of healthcare facility and any type of crisis, end-results will depend on baseline infrastructure and available resources.

Keywords:

• Hospital
• Architecture
• Crisis
• Emergency
• COVID-19
• Disaster
• War

Introduction

During mass-scale crisis, such as public health emergency, military conflict or natural disaster, healthcare facilities struggle to provide evidence-based care to individuals in need. Damage to the healthcare infrastructure can further compromise the delivery of services. Two ongoing crises, the COVID-19 pandemic and the war against Ukraine, have highlighted the magnitude of this problem.

Healthcare facilities during crisis are required to provide medical care, shelter and essential living conditions such as food, sanitation, hygiene and social activities (Chen et al., 2020). This may not be easy to achieve due to challenges such as working in constantly changing and high risk environment, having limited resources, and having to coordinate large, interdisciplinary teams. Effective collaboration between all relevant stakeholders, such as healthcare staff, architects, designers, engineers, and planners; is essential for designing and executing time-sensitive building interventions.

This paper aims to outline key concepts related to healthcare architecture during crises. Particular focus will be given to mental healthcare facilities. The paper will also present key challenges in the field and discuss possible solutions to identified problems. Most examples come from the COVID-19 pandemic, however, as shown below, identified principles can be applied to any type of crisis. Presented views are supported by the author’s work in the field as a psychiatrist and an architect. Furthermore, a non-systematic literature search was performed in PubMed from 1 January 2000 to 1 June 2022, using search words such as ‘architecture’, ‘emergency’, ‘crisis’, and ‘hospital’. Studies were included if they reported any findings related to architecture/urban planning/interior design of healthcare facilities during a large-scale crisis. The main findings are discussed and suggestions for future practice and research have been proposed.

Hospital preparedness

The best crisis response can be expected in facilities prepared for the crisis beforehand. As in many other things in life, advance preparation is the key to success; however, when it comes to healthcare facilities, available guidance is limited.

Ten years ago, WHO developed the Hospital emergency response checklist to assist hospital managers in responding effectively to the most likely disaster scenarios (WHO, 2011). The tool covers nine areas such as Command and control, Communication, Safety and Security, Triage, Surge capacity, Continuity of essential services, Human resources, Logistic and supply management, and Post-disaster recovery. The tool does not have strong focus on hospital built environment, although this aspect is included in two points. For example, one point is that ‘hospitals should ensure that areas for receiving patients are secure from potential environmental hazards and provided with adequate work space, lighting and access to auxiliary power’. The second point states that a comprehensive structural integrity and safety assessment should be performed in case of damage to a hospital building.

Other tools have been developed to assess health-system capacity for crisis management (WHO, 2012), hospital preparedness for epidemics (WHO, 2014), and hospital readiness for COVID-19 (WHO, 2020a). However, these tools do not cover the assessment of hospital built environment. Recently, a tool has been designed to assess flexibility and resilience of healthcare facilities, which is an important factor related to preparedness for crisis (Brambilla et al., 2021). Nine evaluation parameters have been identified, such as shape, structure, façade, building plant, expandability, structural constraints, technology, exchange of large equipments, and functionality. Attempts have been made to assess COVID-19 hospital preparedness, which considered topics such as patient placement, movement of patients within the facility, and visitor access and movement within the facility (Balay-Odao et al., 2020).

To conclude, the field lacks comprehensive guidance and assessment tools related to preparedness of the hospital built environment for crisis. This is problematic because hospital preparedness is integral in maintaining health services and managing the crisis (Balay-Odao et al., 2020). Hospital preparedness for a crisis should consider the full lifespan of a building, starting from selecting the site and designing a resilient facility. Applying innovative approaches in these early stages can improve hospital safety and efficiency without significantly increasing overall costs (PAHO, 2004).

The crisis response

The crisis response has three guiding principles – adaptability, flexibility, and creativity. For example, multiple building typologies have been used to improve response to COVID-19 pandemic, such as converting sports stadiums and convention centres into temporary hospitals, using shipping containers to set up intensive care units, and converting vans into vaccination sites. Small-scale interventions were introduced ‘overnight’ in an attempt to find design solution to public health challenges. These include erecting plexiglass shields between staff and patients, implementing additional handwashing sinks, using floor tape to create spacing between individuals, etc. In most cases, the crisis response employs ad hoc thinking. This is required because construction often begins before plans are finalised and architects and engineers are required to respond to challenges as they emerge.

The crisis interventions can focus on adapting existing healthcare facilities, building new units, and repurposing civil facilities for hospitals. These models are not mutually exclusive and most often co-exist to address the increased demand. More information about each of these models is provided below.

Crisis adaptation of existing healthcare facilities

Healthcare facilities are generally designed with a large degree of flexibility. Like most other buildings, they are likely to remain in function for decades and centuries and, therefore, need to accommodate changes to service delivery and the evolution of technology. In a crisis, the adaptation of multipurpose and flexible spaces is crucial for increasing hospital capacity. The adaptation can include one or several parts, rather than the entire facility, or it can happen in phases, depending on the current demand.

Key principles for crisis adaptation of healthcare facilities:

• Implementing adaptations/interventions that are quick, economic, durable, and easily deployable

• Considering modular construction

• Transforming flexible spaces (e.g. hospital lobbies, corridors, outdoor spaces) into clinical spaces (e.g. triage, screening, treatment areas) using low cost structural interventions (Cammorota et al., 2020)

• Transforming existing accommodation units into treatment or staff spaces

• Providing separate emergency entrances for vulnerable groups (e.g. contagious or traumatised patients),

• Ensuring environmental and building engineering controls (e.g. sufficient and effective ventilation) (Morawska et al., 2020)

• Establishing effective communications

• Establishing waste and supplies management (energy, water, food, and linen)

• Considering potential extensions in case they are needed

Adaptations to hospital environment should, of course, happen in parallel with training of medical/technical staff and the maintenance staff in the use and care of the new environment. In some hospitals, or parts of hospitals, architecture constraints will limit adaptive capacities (Douillet et al., 2021). The creativity of hospital staff, architects, and planners are key to overcoming these types of obstacles.

Building new units

Many aspects of modern healthcare, such as trauma management, have been improved due to lessons learned from military medicine. The same applies to architecture and design of healthcare facilities in times of crisis. The concept of military or field hospitals, first erected during WWI, continues to be used during emergencies (WHO, 2013; WHO-PAHO, 2003). These portable facilities are created to meet immediate emergency requirements for a period of time (Bakowski, 2016). They can be either self-sufficient or complementary to existing stationary hospitals. These hospitals can be built underground, such as in war conflicts in Syria (Attar, 2016), or in repurposed empty buildings during the COVID-19 pandemic in Boston, US (Erickson et al., 2021). The function is always to address quickly the surge or sudden influx of patients and to provide care until the local medical infrastructure is rebuilt and functional.

These temporary hospitals are usually made of modular containers, but can also include tents, pneumatic structures and lightweight constructions. (Bakowski, 2016) The prefabricated modular systems with separate units are the optimal solution, as they can be easily and quickly assembled and disassembled, keeping their ability to being ready-to-use (Bakowski, 2016; Smolova & Smolova, 2021). Good example are hospitals erected during COVID-19 outbreak. Two specialty field hospitals in China – Huoshenshan and Leishenshan – were designed, built and commissioned in less than two weeks. This was achieved due to good collaboration between key stakeholders, implementation of digital technologies, and adopting prefabrication technology to avoid time-consuming in situ construction work (Luo et al., 2020).

The WHO recommendations for COVID-19 community facilities emphasised four aspects of the structural design: modularity or ability of areas to expand and/or be repurposed, separation of areas with different purpose, good visual control between different areas, and clear and efficient patient pathways and staff flows (WHO, 2020a). Interestingly, these aspects of the hospital design can be applicable to any crisis scenario and are not restricted to the COVID-19 pandemic. Similarly, WHO produced guidance regarding transformation of non-healthcare facilities into quarantine or isolation facilities (WHO, 2020). This guidence can apply to any type of crisis as it proposes location with road connection, parking, and telecommunications signal coverage; large space; flat and level floor(s); water, sanitation and hygiene facilities; easy to move patients on trolleys; and appropriate ventilation, preferably natural.

The crisis response may utilise public spaces to increase healthcare system capacity. For example, during COVID-19 pandemic, exhibition centres and sports venues were converted into hospitals. The rationale was simple and straightforward, these venues were widely available, flexible in their design, and had good power supplies and ventilation already in place. Good examples include Fangcang shelter hospitals in China (Chen et al., 2020), quarantine facility in Singapore (Chia et al., 2021), Nightingale hospitals in the United Kingdom (Pearman, 2020; Anandaciva, 2021), and repurposed convention centre in Central America (Bello et al., 2020).

Since the COVID-19 outbreak, China has adopted three methods of admitting patients for treatment: designated hospitals, newly built temporary hospitals and Fangcang shelter hospitals. The Fangcang shelter hospital is a novel public health concept developed in Wuhan, China at the beginning of the COVID-19 outbreak in 2019 (Chen et al., 2020). The Fangcang shelter hospitals were rapidly built by converting existing public venues, such as stadiums and exhibition centres, into healthcare facilities. This typology was characterised with rapid construction, massive scale, and low cost. The first three hospitals were converted in remarkable 29 h, providing 4000 beds. In total 16 shelters were provided during 2019–2020, accommodating 12,000 patients. This process involved some interior redesign of spaces and purchasing and installing beds, medical devices, and supplies to support care, monitoring, and sheltered living. The Fangcang shelter hospitals became a national standard of care and the concept was adopted by other counties such as Iran, Serbia, Spain, UK, and US.

The Nightingale field hospitals were built across the UK in 2020 to address the surge of COVID-19 patients (Anandaciva, 2021). Seven were erected in England as a joint initiative between the national health service, national army, and private sector organisations. A NHS Nightingale instruction manual was published showing processes and strategies used on the temporary hospital (BDP, 2020). Interestingly, the surge of patients was successfully absorbed in existing hospitals and, couple of months after being completed, the Nightingales were either put on standby or repurposed as vaccination sites or diagnostic clinics. The lack of staff available to run the Nightingales was the main reason why they were not used as intended. Nevertheless, these hospitals offered hope to people and were seen as the ultimate insurance policy that was not needed in the end (Anandaciva, 2021).

During the COVID-19 pandemic, Singapore implemented large-scale isolation units called Community Care Facilities (CCFs) to combat the outbreak in the community by housing low-risk COVID-19 patients from April to August 2020 (Chia et al., 2021). The CCFs were created rapidly by converting existing public spaces and used a protocolized system, augmented by telemedicine to enable a low health care worker-patient ratio.

Interestingly, during crises even obsolete healthcare facilities can be repurposed and back in use. For example, during war conflicts or earthquakes, modern facilities can be severely compromised and patients may need to be transferred to facilities that were previously no longer in use. During COVID-19 pandemic these old facilities were praised for having windows designed to be opened and to allow access to uncontaminated air. This is another example of the importance of flexibility in hospital design as well as fine balance between advanced technology and basic building principles.

Mental health units and psychiatric beds in times of crisis

Almost all people affected by large-scale crises will experience psychological distress and the majority will recover completely over time (WHO, 2022). Global estimates indicate significant increase in the prevalence of major depression and anxiety disorders due to the COVID-19 pandemic (COVID-19 Mental Disorders Collaborators, 2021). Individuals with severe mental disorders, women and young people are particularly vulnerable during crises and it is essential that they can access good quality mental health care.

The health-care systems face increased demand for provision of mental health care during and after crises. In most countries hospital beds for people with mental health disorders can be found within general hospitals or in specialist mental health units. Psychiatric hospital beds are known to be easily affected by health system transformations and budget cuts. Over the last couple of decades most countries have opted for steady reduction in psychiatric hospital beds. This was supposed to be matched with innovations and increased availability of community mental health care. However, very often the outcome of reduced number of psychiatric beds is that both inpatient and community services end up functioning under enormous pressures.

Theshortage of beds is the baseline position for mental health services, and yet, further reductions can happen in the times of crisis. The COVID-19 pandemic had dramatically cut the availability of psychiatric hospital beds. Psychiatric wards had been downsized to meet social distancing requirements, for example, double-occupancy rooms were transformed into single-occupancy rooms to reduce viral spread. In a different model, psychiatric wards were repurposed to increase the capacity to care for COVID-19 patients (Adorjan et al., 2021; Rapoport, 2020). A study from Germany indicated that both emergency hospital admissions and length of hospital stay significantly increased for a broad range of psychiatric disorders during the COVID-19 outbreak (Fasshauer et al., 2021). Increased availability of community resources and interventions can be helpful for the majority of affected individuals. However, the most vulnerable individuals may struggle to engage with community-based interventions and are likely to require hospital admission to improve their health. These learnings need to be taken into account when making contingency plans and preparing for the next crisis.

Challenges related to crisis healthcare architecture

Healthcare facilities operating during crisis may not satisfy some basic principles of effective patient care, such as good staffing levels, necessary medical equipment, and professional expertise. Regarding healthcare architecture, key challenges include ensuring an effective spatial platform for health care delivery in temporary facilities, establishing links with existing facilities and health services, and considering post-crisis life of built interventions.

The crisis interventions need to provide ‘good enough’ space for patients and staff. This often means meeting minimal requirements related to patient and staff safety. In these circumstances some aspects of hospital built environment may not be provided such as adequate patient personal space, good signage and orientation points, adequate natural daylight, views, landscape, natural ventilation (Verderber, 2021). How to maintain culture and social life in healthcare facilities during crisis is often neglected, but very important aspect of everyday functioning. Other challenges include good IT support, efficient hospital information system, equipment maintenance and medical staff training (He et al., 2021). The solutions to these challenges will look different for each facility, depending on the baseline infrastructure and the type of crisis.

Importantly, challenges extend beyond providing patient care. As hospitals have responded by converting every available space for patient care, staff areas are reduced, thus preventing staff from having space and opportunities to rest and decompress.

Other challenges include establishing functional and spatial links between temporary and permanent facilities, sustainability, and post-crisis life of built interventions (PAHO/WHO, 2003).

Interestingly, the COVID-19 pandemic demonstrated the failure of healthcare facilities across the world to meet demand in times of crisis and has inspired architects to rethink current concepts for hospital architecture. Some argue that the hospital of the future must exist on a more decentralised platform, both physically and digitally, and be more flexible in function (Park, 2022).

Conclusion

Our world is constantly changing and communities continue to be affected by the impact of climate change, military conflicts, natural disasters, rapid urbanisation, and economic crises. New mass-scale pandemics will continue to appear at irregular intervals. Are hospitals prepared to react quickly and flexibly to the increased need for treatment and care? Key challenges include ensuring an effective spatial platform for health care delivery in temporary facilities, establishing links with existing facilities and health services, and considering sustainability and post-crisis life of built interventions. Lessons learned from past and ongoing crises indicate the need for architects to plan and design healthcare spaces that have a high degree of adaptability to enable either temporary or permanent changes to occur smoothly. The crisis interventions can focus on adapting existing healthcare facilities, building new units, and repurposing civil facilities for hospitals. The concept of ‘temporary hospital’ should not imply a decrease in hospital technical requirements or in terms of quality of care. Ensuring teamwork from different fields of knowledge (i.e. architecture, engineering, medicine, and nursing) is essential for success. There is no one, fit-to-all strategy, each facility needs unique approaches based on its foundational infrastructure and the type of crisis. However, guiding principles identified in this paper can be used for any type of facility and any type of crisis.

Disclosure statement

No potential conflict of interest was reported by the author(s).