Five Ways to Improve Hospital Infection Control as Coronavirus Tests Health Care Providers

By James Lennon

With coronavirus cases multiplying worldwide, many infected patients will seek emergency care at local hospitals, exposing other vulnerable people and the caregivers treating them. This outbreak highlights the urgent need for rigorous infection control in the medical facilities on the front lines.

The obvious challenge during a pandemic is treating everyone who needs medical care while keeping uninfected people from contracting the disease. But complicating matters right now is the novel nature of the coronavirus disease, known as COVID-19, as scientists try to pin down all the ways it’s transmitted and how long the virus survives on surfaces.

HKS has researched and executed advanced strategies for the management of infectious diseases in hospitals for the last 15 years. During that time, we have created cost-effective architectural layouts and procedures that allow hospitals to effectively manage infected patients while protecting caregivers.

Each hospital has its own mission and set of considerations, so there are no cookie-cutter design solutions. Often, the most relevant infection control approaches are those that not only prevent the spread of disease but also address other problems.

The following strategies can improve how we protect hospital staff and patients from infection:

  1. Segregate patients before entering the hospital and provide more than one entry.

This is a very simple concept: If the single entry to a hospital becomes contaminated, the hospital can’t receive patients. Given this potential hazard, patients should be evaluated for infection or contamination before entering the facility. Allowing patients with pathogens into the facility without identifying the infected from the non-infected risks infecting caregivers and other patients and compromising the hospital’s ability to deliver care. We have seen this in New York, where a patient’s coronavirus disease went undetected for several days at a suburban hospital, leaving hospital staff and other patients exposed. At least one hospital worker was infected, and an untold number of other workers who cared for the patient are in quarantine, according to The New York Times.

Special portals can be designed to facilitate the testing of patients before they step into the hospital. The concept of multiple portals as entry points to an emergency department was one of the design recommendations in ER One, a study in the 2000s funded by the U.S. government to research and design an all-risk-ready emergency department in Washington, D.C. The idea was to create a facility in the nation’s capital that would be prepared to respond to epidemics and mass-casualty events such as bomb detonations and bioterrorism, serving as a model for other emergency departments. Though ER One was never built, the 1,000-page report remains the only comprehensive design and operational document aimed at infection control produced anywhere to this date. HKS helped craft the report, portions of which have been implemented at various hospitals worldwide.

The above image is the floor plan of ER One, with the red dots representing the locations of the portals.

The portals in the ER One concept each have two chambers that can be sealed. They serve as a barrier between untested patients — infected and uninfected — and the rest of the hospital. Patients would step into one of the chambers, where sensors now on the market can measure temperature, heart rate and other vitals. The design provides a protected security area between both chambers where medical staff can be stationed to screen patients and then direct them to their next destination. Health care providers can equip the portals with metal detectors to boost security in day-to-day operations.

  1. Separate patients and visitors from medical staff by creating independent circulation areas.

The typical emergency department is designed to have patients, family members and hospital workers circulating through the same area, thus risking cross-contamination. After the deadly 2003 SARS outbreak in Toronto that began with a chain of transmission at Scarborough Grace Hospital, officials with the hospital determined that the reason so many medical workers became infected was that patients’ asymptomatic relatives were spreading the disease by touching and contaminating hospital surfaces.

Patients, families and support hospital workers (X-ray, lab and housekeeping staff, for example) should not be mixed with medical caregivers. Creating two separate corridors — one on the periphery for patients and families and another in the hospital core exclusively for medical staff — protects the people and resources critical to treating infected patients. Under this model, which is another ER One recommendation, all patient rooms would have two doors: one from the patients’ hallway and one from the staff work area core. This concept has been designed into many existing emergency departments such as the ones at Duke University Hospital and Wake Forest Baptist Medical Center University in North Carolina and York Hospital in Pennsylvania, to name a few.

Infected people should be streamed into a sequestered area in the facility. The ER One concept featured patient room clusters that could be separated with sliding partitions to facilitate isolation.  A separate air handling system should serve the infected individuals. Infected and non-infected people sharing potentially contaminated air would clearly put the non-infected at risk of accidental infection. A pressure gradient must exist between the sick, well and staff that encourages negative air flow in the infected areas relative to the rest of the hospital. Negative-pressure rooms suck in air from the outside, as opposed to blowing out contaminated air.

The Virginia Commonwealth University Medical Center emergency department was designed with a dedicated 22-bed infectious disease treatment area with a separate air conditioning system. This unit is expensive, functioning as an observation unit when not in use for infectious disease to capitalize on the investment. Though these units require a lot of capital, they would be a welcome resource in places like Washington state, where the coronavirus outbreak has prompted government officials to look at buying a motel to isolate infected patients.

  1. Create unidirectional flow from the rooms of highly infectious patients.

Anterooms were designed as an additional barrier between infectious patients and the rest of the hospital — a safety zone where medical staff could wash their hands and put on personal protection equipment before entering a patient room, and later doff their gowns on their way out. The problem with these spaces is that staff return the same way they came in, potentially contaminating clean areas.

A better strategy that we’ve researched at HKS is an exit room on the back side of an isolation room. This room could be used for de-gowning and provide space for cleansing and showering and for the containment and disposal of contaminated materials. This design eliminates the need for caregivers to backtrack and compromise clean spaces.

This design concept has been well received and adopted in several HKS-designed emergency departments. For example, Banner Health’s University Medical Center Phoenix is prepared to manage infectious patients with illnesses as deadly as Ebola by using unidirectional infectious disease rooms.

Exit rooms are quite efficient designs. But many architects and hospital executives aren’t educated about the need for these spaces, and current U.S. design and construction codes for isolation rooms don’t require exit rooms.

  1. Create patient rooms that are easier to clean.

With so much equipment in the walls of patient rooms, how do you clean every nook and cranny? ER One’s patient rooms were designed to be made of a seamless plastic that is easier to wipe clean that other materials. The rooms’ walls would be marked with a red band that would circle the room to encompass frequently touched items such as light switches, hospital equipment and anything else that needs to be constantly cleaned. The strip concentrates those items in a clearly marked area that makes all these items impossible to miss, as opposed to the design scattering all these things around the room and complicating the cleaning process. Housekeepers would clean the items on the “high touch” strip first and do so thoroughly, minimizing the transfer of bacteria or viruses.

In addition, all lights, air conditioning and devices to distract patients such as TVs would shine through a translucent ceiling to create a surface that could be quickly disinfected. The corners of the room are rounded to further facilitate cleaning.

  1. Shield hospital equipment from patients to the extent possible.

In a traditional emergency department exam room, there are several exposed items near the patient — IV poles, monitors, diagnostic devices connected to the wall — that offer crevices and cracks where bacteria or viruses can hide.

Emergency Department pods at Northwestern Memorial Healthcare in Chicago

Emergency department examination “pods” for low-acuity patients are designed to reduce possible infection by separating the patient from complicated equipment that may be clean, hence reducing the chance of contaminating the equipment. The pods, a fraction of the size of a traditional exam room, borrow from the ER One patient room concept above. These spaces are made of a dense, smooth plastic that can be quickly wiped down to provide a safe, clean area for a patients, family members and staff. Medical equipment sits behind smooth compartments that hospital workers can open with a remote control.  At Northwestern Memorial Hospital’s emergency department in Chicago, the only medical items that are accessible to patients in the low-acuity pods are exam gloves.

This design offers another advantage by preventing patients from knocking down or tampering with medical equipment.

James Lennon

James Lennon is an architectural specialist at HKS. He’s a frequent lecturer on emergency department design in the U.S. and abroad and created the “emergency department of the future” course taught for more than a decade at Harvard University. James has spent hundreds of hours in EDs observing patient and staff flow and pioneered the use of discrete event simulations in ED design.