Pandemics and Healthcare Design: The Impact of the Coronavirus

The coronavirus has had a significant effect on healthcare, with a surge of new temporary hospitals requiring architects to come up with innovative solutions to convert existing spaces. But how could it impact long-term healthcare design? Alex Love speaks to architects involved in hospital design to find out

The Covid-19 outbreak has pushed healthcare facilities around the world to their limit. Authorities have been forced to take urgent action to address the rising demand for beds.

To alleviate the burden on hospitals, a number of temporary healthcare facilities have been needed. Collaborations between governments, architects, builders, suppliers and even the army have happened on a scale and pace rarely witnessed during peacetime to meet the extraordinary challenges.

“Staff shortages were a challenge already before the pandemic. And now for everybody, it’s a war going on - so all driving forces go in one direction. But we have to design healthcare environments that will last for the long-run, and that will also be reliable environments for the staff to work in,” says Charlotte Ruben, architect and partner at White Arkitekter, based in Sweden.

In England, seven temporary Nightingale hospitals have been established, taking over venues such as events centres and indoor arenas to add approximately 8,000 beds to the nation’s capacity. This is in addition to a further ten field hospitals dotted around the UK.

Manchester Nightingale: A rapidly deployed hospital for pandemic response

In Manchester, the Nightingale Hospital is situated in the Manchester Central Convention Complex, covering 14,500m2. With barely any notice, design and construction teams sprung into action to get it built.

"We had two weeks from a standing start to develop the brief, develop the design, do the mock-ups, get the design signed off,” explains Ged Couser, a principal director at BDP architects, specialists in healthcare design. The firm has been involved with the design of six Nightingale hospitals in England.

“We literally had 12 hours notice to put the team together and we'd start work first thing on Monday morning. I was based on site for 13 days, and had a team of about ten people. Five on site, five working from home – modelling. And we have a brilliant team, across both disciplines - architecture and M&E,” adds Couser.

“ We had two weeks from a standing start to develop the brief, develop the design, do the mock-ups, get the design signed off. 

“I think there were about ten architects, probably about ten M&E engineers all doing 15, 16, 17 hour days for the duration. It only worked because we had such a collaborative team between BDP, IHP, Sir Robert McAlpine and Vinci, all in the same room, all working out problems on the spot.”

The timeframe to design and build the interior of the temporary hospital was significantly shorter than the teams were used to. Nevertheless, they found a way to deliver the project on the strictest of schedules.

“All the design and construction activity was happening on site all at the same time. I think when we finally handed over the end general arrangement during the final drawing, we're up to revision 15 – which is quite a thing in 13 days,” adds Couser.

“Normally, to deliver a 750-bed hospital would take between four and five years. But obviously, it's a different proposition – it’s difficult to make that kind of comparison.”

Manchester Nightingale was constructed in the Manchester Central Convention Complex in less than two weeks. Image courtesy of BDP

Overcoming design challenges

BDP has an extensive portfolio in healthcare facilities, having designed the new Alder Hey Children’s Hospital, and the recently completed Clatterbridge Cancer Centre in Merseyside.

“We know how big hospitals work, so we applied that experience,” says Couser.

Aside from the tight timeframe, what made the project all the more challenging was that Manchester Central also has the constraints of being a Grade II-listed building not designed for healthcare use.

However, what makes Covid-19 a unique challenge for healthcare facilities is the virus’s high infection rate. As a result, the designs needed to carefully consider the best ways to minimise transmission.

“We had to very definitely separate the red zone - which is the Covid-infected zone where staff need PPE – with the amber zone, where staff are in scrubs unless coming into contact with infected patients. And then with a green zone where all the goods, all the food, all that stuff, could come into the infected space, but via safe routes that staff not necessarily wearing PPE could use. Getting that flow within the constraints of the existing building was quite a challenge,” explains Couser.

“ Those are lessons I think we can all learn in terms of how healthcare facilities get delivered in future. 

Throughout development, designers received assistance from government experts in infectious diseases and it led to some design innovations.

“To get the food, the linen, and all the clean consumables into the wards, we designed a pass-through hatch, which allowed people on the green side to not come into contact with surfaces and staff within the red zone. Which meant the building could operate really very efficiently. Those hatches were at the heads of the countertops of each of the wards. And that seems to be working really well,” adds Couser.

According to Couser, the army’s involvement made communications more concise and helped speed-up operations.

“The other thing that was really interesting was getting the efficiency in terms of asking questions of the client and getting responses back. We had two windows of opportunity to do that during the day, one mid-morning and one in the early evening,” he says.

“We asked questions in the morning, got the answers back in the afternoon. And then the army facilitated that by stopping meetings being no more than 15-20 minutes long. All the attendees would stand up, and Major Matt Fry talked about concentrating and pulling the big levers, getting the big problems resolved and sorted in the right order, so construction activities could keep going. Those are lessons I think we can all learn in terms of how healthcare facilities get delivered in future.”

Karolinska University Hospital in Solna, Sweden, has had 23 of its new operating theatres turned into intensive care wards to treat coronavirus patients.  Image courtesy of Anders Bobert, White Arkitekter

Designing flexibility into healthcare

While Sweden has implemented restrictions to curb coronavirus transmission, these measures haven’t been as strict as other countries and it hasn’t entered a formal lockdown. During the pandemic, Swedish hospitals have come under considerable strain.

Healthcare providers have had no option but to adapt and flexibility has been vital in achieving this. The new Karolinska University Hospital in Solna has had operating theatres turned into intensive care units for coronavirus patients.

“We designed 23 operating theatres. In Sweden, it has even become a standard now that we locate operating theatres along facades – instead of having the corridors along facades - to bring in the daylight to create a healing environment and attractive working environment for the staff,” adds Charlotte Ruben from White Arkitekter.

“ The project was supposed to be open for operating procedures in April, then the pandemic came. 

“The project was supposed to be open for operating procedures in April, then the pandemic came. These 23 operating theatres were then instead transformed into intensive care units for three patients in each operating theatre. Equipment for surgery – the gases, the monitors and everything - they were taken out. And the equipment that came in was for respirators and intensive care.

“I was thinking afterwards: why was this possible to actually convert operating theatres into intensive care units? And it was because of daylight. So the staff could actually work for however long that is needed; and that it that it is an acceptable working environment.

“Also, of course with the air flow there are a lot of benefits also to transform these intensive care units, because you have the highest requirement on air flows in intensive care units compared to standard patient wards.”

Karolinska University Hospital in Solna. Image courtesy of Anders Bobert, White Arkitekter

The Covid-19 legacy

The longer Covid-19 lasts for, the more difficult it will be for things to go back to the way they were before. It is hoped that the experience gained during these challenging times will benefit the construction industry in the years ahead, with the efficiency of communications something that teams involved with the temporary hospitals are keen to maintain.

“These Nightingale centres really prove what is possible,” adds Ged Couser. “This sort of gets decision-making time to finer point and to a much slicker process. I think that that will benefit everybody.

“The lessons learned have been passed down all the way through the organisation and across the P22 Supply Chain, which I think is really testament to the quality of the industry. Information was really free-flowing across all the supply chain and between all the teams, which was really useful.

“The NHS is performing absolute heroics at the minute and I’m just pleased the construction industry has been able to contribute to that.

“They might not be used to the full extent and hopefully they’re not going to be, but to have the worst case scenario covered is an important achievement.

“ I just think we really need to take a step back and really think about what the NHS and what the healthcare estate needs to look like in the future. I think flexibility is absolutely the key to it. 

“I just think we really need to take a step back and really think about what the NHS and what the healthcare estate needs to look like in the future. I think flexibility is absolutely the key to it.”

One of the unfortunate consequences of the pandemic is that people with other health conditions who should be attending hospitals have been reluctant to for fear of either contracting COVID-19, or what they perceive as taking up the invaluable time and resources of healthcare facilities. Ultimately, this could result in peoples’ medical conditions worsening and they may need a more intensive level of treatment.

In response to this, some are predicting that mobile medical units will be more common in future, allowing patients to be treated away from hospitals.

“The temporary solution must also be much smarter and that it shouldn't be only about the field hospital concept, but also how we can develop small mobile units. That's a design task for architects and engineers - how we can make mobile units to handle more critical situations for home care,” adds Charlotte Ruben.

“The hospital is, in one way, becoming more specialised. And I think there will be fewer hospitals, but more advanced hospitals in the future.”