Officials at Rady Children’s Hospital in San Diego had already begun work on a $1.2 billion transformation of its campus when the pandemic hit, forcing them to switch gears. As hospitals nationwide struggled to deal with surging cases, it became clear that the facility’s new design would need to evolve.
“When the pandemic came along, it really changed the lens of how we do health care design,” said Dr. Nicholas Holmes, chief operating officer of Rady, the only children’s hospital in San Diego County and the largest in California. “And what we learned over the past few years, first and foremost, is to be as flexible in the design process as we can.”
The early waves of the pandemic came crashing into hospitals, revealing intensive care units without enough beds, hallways and waiting rooms that forced the healthy and sick to commingle, and ventilation systems that became conduits for airborne pathogens. Given that hindsight, many hospitals are remodeling with a philosophy of flexible design, the idea that spaces should be adaptable for different purposes at different times. When the next pandemic comes, they’ll be able to better meet the moment.
Traditional hospital design calls for sections that sequester the most vulnerable and contagious patients, with features not found in ordinary inpatient rooms. These include changeable airflow systems to keep microorganisms from traveling beyond the room’s walls; headwalls behind beds for electric, gas and equipment mounts; and, in general, a larger floor plan to accommodate specialized equipment like ventilators.
In times of crisis, hospitals require more of these specialized spaces, with different protocols of isolation for different diseases.
At Rady Children’s Hospital, where a new seven-story tower will house an intensive care unit as well as an emergency department, designers looked at the lessons learned from the pandemic and scrapped the tower’s original rectangular floor plan. In its place, they created one shaped like an X, with a 60-bed floor plan that can be converted into 20 fully isolated rooms for infectious-disease patients, should the need arise.
“Rather than looking at it on a single-room basis, when you think about maximum flexibility, you think about banks of rooms,” Dr. Holmes said. “Seeing it through that lens allows you to not have to transfer patients who are moderately sick into critically intensive care units.”
Much of the shift in hospital design revolves around surge capacity, which is how health care workers adapt inside their buildings when the number of sick patients jumps substantially. In March and April 2020, the sudden rise in contagious patients meant some hospitals were scrambling to find beds, setting up overflow tents in parking lots and rationing equipment.
“During the pandemic, they were doing hopscotch or leapfrog; they had to adapt on the fly,” said Douglas King, vice president of health care at Project Management Advisors, a real estate consulting firm. “Now hospitals are identifying wards, usually of 24 to 32 beds, and they can stack some of those wards together to become pandemic wards.”
To prepare for that shift, designers are thinking about how traditional rooms can quickly morph into isolation wards by upgrading or overhauling their heating, ventilation and air-conditioning systems. Fabrics and finishes, too, are being reconsidered, with an eye toward durable materials that can withstand industrial-level scrubbing.
Finally, the pathways that lead to these wards need to be rethought, Mr. King said, “so the transportation for patients and staff allows these spaces to be isolated and operated independently from the rest of the hospital.”
A new I.C.U. at Doylestown Hospital in Doylestown, Pa., which opened in 2021, has private rooms meant to flex between intensive care and step-down care. The rooms are clustered in pods of eight to reduce traffic in corridors.
It will be the second new wing with flexible design at Doylestown. After realizing that a new wing for heart and vascular care that opened in January 2020 could be used for critically ill Covid-19 patients during the pandemic, hospital administrators leaned into flexible design.
“The pandemic proved the need to have flexible space,” said Jim Brexler, chief executive of Doylestown Health. “The impact of having adequate critical care space was essential, and you don’t want to build all that out and not be able to use it for other purposes.
“This is the future of hospitals,” he added.
CannonDesign, an architecture firm in New York, was involved in two hospital expansion projects.
At Barnes-Jewish Hospital in St. Louis, workers broke ground on a 16-story inpatient tower in 2021, including acute-care rooms that can morph into I.C.U. rooms. To achieve that flexibility, designers included additional outlets for medical gas and electricity, and larger clearances around beds to accommodate extra equipment. The upper half of doors will be made of glass to allow practitioners to observe highly contagious patients without entering the room.
And at WellSpan Health in York, Pa., an eight-story surgical and critical care tower being built as part of a $398 million hospital expansion will have oversize patient rooms that can function as spaces for critical care.
“The general sense that I get is that this is not a one-time situation that we just went through with Covid,” said Jocelyn Stroupe, co-director of health interiors for CannonDesign. “It’s just one of many infectious disease conditions that we’re going to be experiencing in the coming decades.”
Preparations for those disease conditions can be seen on other construction sites across the nation.
Ballantyne Medical Center, a 168,000-square-foot hospital in Charlotte, N.C., scheduled to open next year, will feature dual headwalls for more capacity in patient rooms and ventilation systems that allow rooms to be converted to negative pressure ones that prevent harmful airborne particles from flowing into other spaces. An outpatient center being built as part of a $151 million renovation at Grady Memorial Hospital in Atlanta will have flexible rooms with mobile equipment that can quickly be transferred from space to space.
And in Los Angeles, CHA Hollywood Presbyterian Medical Center plans to open a new patient tower in 2023 with larger waiting rooms that allow for distancing, more rooms with negative pressure ventilation and a tripled capacity for blood-oxygen monitoring systems. Thirty-three private rooms are being added as well, all of which can be reconfigured for surge capacity.
The focus on flexible design is not unique to hospitals, said John Swift, who leads the health care sector at the engineering and design consulting firm Buro Happold. Three years into the pandemic, it has become an almost universal concern.
“We’re seeing these trends not just in health care but in all the facilities we do work in, from laboratory buildings to institutional buildings on college campuses,” he said.
The shift to flexible design will mean that, in the short term at least, some hospitals are better equipped than others to handle the next pandemic. And it will also exacerbate the gap between the haves and have-nots in health care, said Armstead Jones, a strategic real estate adviser for Real Estate Bees.
“You have hospitals that are barely holding on in rural areas, and they can’t afford flexibility in architecture. So what does it look like to them?” he said.
But in the long term, designers expect the lessons from the coronavirus to resonate. Pandemic modifications, they say, are likely to eventually be written into law, much like access for those in wheelchairs and structural requirements for earthquakes.
“This is no different from the code updates we go through every time there is an earthquake in California,” said Carlos L. Amato, a health care architect with Cannon Design. “The lessons learned postpandemic will eventually make it into building codes.”