COVID-19 and the Built Environment
The “built environment” in healthcare refers to the hospital structure and any other fixed or semi-permanent components of the facility with which healthcare personnel, patients, and their families must interact.1 Research has demonstrated that the built environment plays a critical role in the safety of patient care. For example, poor lighting has been linked to medication and order entry errors;2 noise can impact effective communication;2 and factors such as the air, water, room occupancy, surface finishes, and presence of handwashing stations are all components of the environment that contribute to the spread of healthcare-acquired infections.1,2
Given the infectious nature of COVID-19, the built environment can play a role in affecting transmissibility. Researchers, healthcare professionals, and healthcare architects and engineers have identified numerous areas of risk, offered mitigating solutions, and must now consider what modifications are necessary moving forward to continue to improve the safety of healthcare facilities, not just in response to COVID-19, but to foster resilience and capabilities for the next unknown threat to the healthcare system.
Areas of Risk within the Healthcare Built Environment Due to COVID 19
Throughout the pandemic, emergency departments (EDs) around the world have been a critical frontline resource for individuals experiencing more severe COVID-19 symptoms.3 However, the ED remains the setting of care for patients needing emergency medical services for other serious conditions, such as stroke or trauma. The influx of potentially contagious individuals experiencing COVID-19 symptoms to this setting then places these other patients at risk of contracting the virus. In such a highly trafficked, often overcrowded, area of the hospital, the challenge for healthcare personnel becomes how to effectively and efficiently identify and separate those potentially contagious patients from those with other emergency conditions to prevent the ED from becoming a source of continued spread.
To address this risk, EDs have taken steps to work within the limitations of their built environment. For example, patients are often not allowed to be accompanied by a friend or family member to limit the number of individuals in the enclosed ED space, and upon arrival, are screened for COVID-19 to immediately differentiate between COVID-19 patients and non-COVID-19 patients. Some facilities have even put in place drive-through testing facilities. Following screening, hospitals are employing separating techniques to ensure physical distancing of non-COVID-19 patients from potentially contagious patients. In some hospitals, patients displaying signs of COVID-19 are prevented from entering the primary waiting room. Other facilities have separate entrances and wings/units dedicated to potentially contagious patients or are using negative pressure rooms for patients testing positive for infection.4 In addition to physical separation, EDs have intensified cleaning procedures between patients, particularly of high-touch surfaces and equipment.4
Healthcare Facility Waiting Rooms
Since the early days of the pandemic, social distancing has been a key tactic advocated by public health experts to prevent the risk of transmission. Given that new consideration, waiting rooms as designed prior to the pandemic were poorly suited to ensure that patients could maintain 6 feet of separation. In addition to transitioning appointments to telehealth and adjusting scheduling to greatly reduce the number of patients seen within a facility during the course of the day, facilities have been able to make physical modifications to their waiting room environments to support social distancing and patient safety. Facilities have chosen to remove chairs from their waiting rooms, create separate waiting rooms for those displaying signs of COVID-19, and designate alternative waiting rooms and check-in processes outside of the facility to further minimize the number of patients inside a facility at any given time.5,6
Operating Rooms (ORs) and Other Facility Environments
While many elective procedures were initially postponed, as the pandemic has continued, providers have been forced to explore innovative ways of providing usual care as safely as possible for both patients and personnel. The physically close and enclosed nature of some procedures presents risk for transmission during the procedure itself, but also raises questions of how the environment surrounding the procedure could be affected by a potentially contagious patient. For example, OR ventilation systems that are usually designed to create a positive pressure environment that quickly filters air out of the room to minimize the risk of airborne particles to surgical patients may then pose a risk of circulating contaminated air to other parts of the hospital.7
Facilities are employing innovative solutions to keep their operating and procedure rooms and the surrounding environment safe, most notably by using the existing ventilation systems. One example is establishing dedicated negative pressure procedure rooms, and even ORs, for patients with confirmed or suspected COVID-19. The intention is to ensure that any airborne COVID-19 particles are kept within a given room, as opposed to filtered into the neighboring environment. While this may increase the potential exposure to healthcare personnel practicing within the negative pressure environment, infection from airborne particles has been found to be low when staff don appropriate personal protective equipment (PPE).7
Another example, as has been described in other Perspectives, is the increased use of telehealth techniques to evaluate patients within the hospital, combined with transitioning medical equipment to outside the patient room. A final example is the creation of COVID-19-specific wards and wings within the facility in an effort to limit non-COVID-19 patients’ exposure to environments that may have infectious particles in the air or lingering on surfaces.
Impact on the Healthcare Built Environment Moving Forward
As the healthcare community and healthcare architects look beyond the crisis response to the pandemic, the question becomes how COVID-19 – and what has been learned about infection control – will impact how the healthcare built environment is approached in the future. Hospital EDs and other outpatient clinics may wish to consider more seamless integration of screening processes into facility entry points, creation of more permanent segregation of potentially contagious patients in waiting rooms, and perhaps also maintenance of reduced capacity to allow for more physical distance. In further support of physical distancing, both inpatient and outpatient facilities may need to consider whether they have adequate space available for the expansion of more permanent Health Insurance Portability and Accountability Act-compliant telehealth service offerings. Outside of the design elements, there is the opportunity to consider the incorporation of more sophisticated testing of the surrounding environment. This may involve implementation of more robust environmental risk management programs. For example, including regular testing of surfaces, water, and air for infectious contaminants.
Ultimately, facilities may need to prioritize what new practices to incorporate into their built environment keeping in mind that experts caution against using COVID-19 as the only guidepost for what constitutes a safe environment. However, as guidelines recommending safety parameters of the built environment are updated, there is a clear opportunity to consider how the design of healthcare facilities can better prepare facilities for infectious disease management in the future.
In her professional capacity, Dr. Joseph serves as Principal Investigator for an AHRQ Patient Safety Learning Lab (PSLL) project focused on human-centered design in the operating room. Dr. Scanlon volunteers with the American Institute of Architects, supporting their COVID-19 response.
Anjali Joseph, PhD
Spartanburg Regional Healthcare System Endowed Chair in Architecture and Health Design
Molly M. Scanlon, PhD, FAIA, FACHA
Director of Standards, Compliance, and Research
Eleanor Fitall, MPH
Senior Research Associate, IMPAQ Health
Kendall K. Hall, MD, MS
Managing Director, IMPAQ Health
Kate R. Hough, MA
Editor, IMPAQ Health
1. Zimring C, Denham ME, Jacob JT, et al. Understanding the Role of Health Care Facility Design in the Acquisition and Prevention of HAIs. Prepared by Georgia Institute of Technology, Emory School of Medicine, and RTI International under contract HHSA29020100000241I). AHRQ Publication No. 13-0053-EF. Agency for Healthcare Research and Quality; 2013. https://www.ahrq.gov/sites/default/files/publications/files/haidesign-summary.pdf
2. Henriksen K, Battles JB, Keyes MB, Grady ML, editors. Culture and Redesign. Agency for Healthcare Research and Quality; 2008. Advances in Patient Safety: New Directions and Alternatives; vol. 2. [PSNet]
4. How ERs are adapting to keep communities safe during COVID-19. American College of Emergency Physicians. Accessed March 24, 2021.https://www.emergencyphysicians.org/article/covid19/How-ER-are-Adapting-to-Keep-Communities-Safe-during-COVID-19
5. Healthcare facilities: managing operations during the COVID-19 pandemic. Centers for Disease Control and Prevention. Updated March 17, 2021. Accessed March 24, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-hcf.html
6. Checklist to prepare physician offices for COVID-19. American Academy of Family Physicians. Accessed March 24, 2021. https://www.aafp.org/dam/AAFP/documents/patient_care/public_health/COVID-19%20Office%20Prep%20Checklist.pdf