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and any surge in healthcare demand on medical teams. Extensive support spaces are built in for staff arriving for shifts and storage of supplies and equipment, and administrative areas are designed to aid ease of conversion to additional staff respite areas during surge scenarios. It seems unlikely that the Singapore model can be adopted in full in many other locations, including the UK, due to the costs involved. However, there are some critical elements that can be implemented without onerous levels of investment. One advantage of the NHS funding and organisational model is that the UK ought to be able to set a national strategy which can be rolled out across the country. This enables a more coordinated response than the fragmented approach we’ve seen in the US, for example.

Considering the needs of the UK Without the previous experience of epidemics, or a design strategy already in place to increase crisis resilience and surge capacity in our hospitals, the UK has implemented a Nightingale field hospital build programme to create the facilities required to isolate and treat COVID-19 patients during the peak of the pandemic. The speed and efficiency with which these have been put in place, with the help and guidance of the Army, has been impressive. The versatile space of exhibition venues, designed for ease of reconfiguration, has been leveraged to create an environment where mechanical and electrical services can easily be supplied to the bedside, and this has offered scalability of healthcare services in the high population density locations worst affected by the virus. The problem with this response, however, is that it is entirely reactive. While the field hospitals offer capacity, they do not provide flexibility, and are designed only for specific treatment of COVID-19, with only limited potential for additional treatments, should any be required. Nor do they offer the potential for varied levels of acuity, unlike conventional hospital settings, where patients are moved into ICU only when it becomes absolutely necessary, and back to the ward when they are sufficiently recovered. They also raise the delicate question of when and whether it is advisable to move patients from one location to another, making the additional capacity difficult to manage.

Nightingale hospitals answering an immediate demand

As a result, the Nightingale hospitals are answering an immediate demand, but they should not be the lynchpin of a long- term crisis resilience and surge capacity strategy. That strategy must lie with the way in which we design permanent healthcare assets. The good news is that

60 Health Estate Journal September 2020

Stantec argues for incorporating a higher acuity level into single occupancy rooms, and cites the potential for more equipment to be deployed at the bedside.

we have already been implementing a key element of building improved resilience into contemporary healthcare projects for some time, with a single occupancy bedroom model in preference to multi- occupancy wards. This approach has been driven by the infection control benefits it offers and, in a pandemic response scenario, enables patients to be isolated. However, we need to consider incorporating a higher acuity level into single occupancy rooms, and the potential for more equipment to be deployed at the bedside. Although this would involve a significant investment, both as a refurbishment solution for existing assets, and as a design parameter for new facilities, it would ensure that patient accommodation could be upgraded to deal with pandemic or crisis response very quickly.

Using non-medical areas When it comes to capacity, we’ve seen many European hospitals using non- medical areas as care and treatment space. As distressing as this may be for relatives to contemplate, it’s actually a good way to approach flexibility and extended capacity as part of a defined strategy for crisis-resilient hospital design. By widening the already significantly sized streets within hospitals required for progressive compartmental evacuation even further, and upgrading the services in these circulation areas, it would be perfectly possible to use these corridors as temporary ICUs, with beds on each side, and space for medical professionals to work. If this is designed into the facility, along with the model adopted in Singapore to zone, compartmentalise, and manage, access routes using pressurised buffer zones, additional, isolated capacity can be brought on line as and when required.

Hospital design should also consider how other areas of the building with high levels of isolation and infection control can be repurposed during a pandemic or crisis. By ensuring that facilities such as operating theatres and imaging suites are located in an area where the circulation route can be segregated as part of a segmentation strategy, these areas can also be repurposed for crisis response. A sensible approach to designing circulation routes aligned to a compartmentation strategy would be to build on the evacuation protocols that are already integral to the fire strategy. This can then form a basis for designated crisis routes, with integrated air-handling regimes of ‘clean’ and ‘dirty’ corridors to define isolation routes for use in a pandemic scenario.

Beyond patient treatment One of the major learning points from the COVID-19 crisis has been that patient treatment is not the only challenge that faces healthcare estates during a pandemic; there are also issues around staff accommodation, testing, and research. These three considerations are intrinsically linked. We have seen different approaches to testing across the world, and it’s clear that the ability to identify who has the virus as early as possible not only helps to ensure that affected patients are quarantined, but also maximises the number of healthcare professionals in work and treating patients. In some countries, drive-through testing facilities have been implemented, but the ideal scenario is to enable testing to take place at a dedicated and isolated facility within the hospital, so that those affected can be transferred directly for treatment if required.

Ideally, areas that can be isolated as testing facilities should be earmarked

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