Experts in the field of health care, as well as those in the design and construction of hospital systems, have been talking for many years about maximizing existing care space and expanding outpatient facilities and telehealth options, but COVID-19 exposed many flaws in hospital systems and brought these issues to the forefront of hospital innovation.
Steve Dickerson, health care architect for Diekema Hamann Architecture + Engineering in Kalamazoo, said the coronavirus crisis revealed financial vulnerabilities in health systems, which previously relied on outpatient care as a primary source of revenue.
“A lot of revenue was lost when they stopped doing voluntary and ambulatory procedures,” Dickerson said, ”so they became a little bit more vulnerable to acquisitions at that point.”
The health care industry is in a unique bind because of COVID-19, said Dan Behler, director of health care and senior living for EV Construction in Holland. Health care usually remained constant in past economic crises that negatively impacted most consumer-driven markets like retail or restaurants, but during the this pandemic, even hospitals weren’t safe.
“Health care has almost always been the constant,” Behler. “People have medical needs, so health care is less affected by these events than consumer-driven markets are, but in this particular case it’s been a bit different because health care actually has been one of the more impacted industries.”
The combined loss of revenue due to the pandemic and the need to continue providing care to patients forced hospitals to look inward rather than outward, Behler said. Hospitals now are exploring ways to best utilize the space they already have.
Tom Tocco, executive director of facilities and construction for Trinity Health, said hospitals optimizing their space could create positives in a number of directions including pandemic response.
By pooling resources in less real estate, health systems have the opportunity to address care needs in a more efficient manner, not just in keeping costs down, but also making sure they have ample resources to deliver that care. At the same time, health systems still are expanding their ambulatory or outpatient care networks to reach as many communities as possible, Tocco said.
“In this way we want to be sure patients are getting the first looks they need with their primary care physicians, because that’s critical, but when you look at a step above that, with other services, yes, you will probably notice a trend,” Tocco said.
Nationally, health systems are looking at new forms of revenue with the drop in voluntary procedures. Enviah, a Grand Rapids-based design firm servicing health care clients around the country, has been privy to many similar discussions.
Dr. Lorissa MacAllister, president and founder of Enviah, added the COVID-19 crisis resulted in an increased utilization of telehealth visits from about 20% pre-pandemic to 80% overall. As a result, Enviah is looking at opportunities to maximize provider productivity with outpatient facilities where patients can be moved from an in-person visit to a virtual visit and improve the system’s return on investment.
MacAllister added hospitals want to have that large presence in communities outside of that urban core, and telehealth can be a good supplement to traditional outpatient care.
“The new marketing opportunity is maybe you don’t need to be physically present in their backyard but having a tele-presence for that client — we’re seeing — may be more important,” MacAllister.
New construction still is a major factor in hospitals providing needed care. EV Construction recently completed a project for Bronson Health Systems, which acquired a group of 60 physicians. The hospital had a set date for the new physicians to be up and running in new offices. EV decided it would be best to copy the design from another office it built in 2017 and build it six more times in the span of 11 months.
“For us, it was a huge task to quickly provide office space for these newly acquired physician groups, but luckily we had an approved design and we were able to turn it into a prototype medical office building,” Behler said.
New construction has been prevalent mostly in the realm of outpatient facilities, Dickerson said. Diekema Hamann currently has two new construction projects on its roster, plus a handful of renovation projects aimed at reconfiguring existing space for maximum efficiency.
“We’re seeing a blend of both,” Dickerson said. “Some of them started pre-COVID … the new builds are definitely leaning toward those ambulatory facilities as a means to put care within those communities as opposed to having a large urban central location.”
Another COVID-19 change EV recognized was a new emphasis on hospitals adapting patient rooms for different acuity levels, like converting a standard patient room into an isolation room or an ICU room where they can receive a coronavirus patient with a respirator.
Behler said EV has been pushing this “acuity-adaptable” room model for a number of years, but with the pandemic there’s been more emphasis on making it a reality.
“Our engineers have been looking at ways to either exhaust the air out of the space to make it near-isolation, maybe not full-isolation, but closer to an isolation room,” Behler said.
Tocco said most of Trinity Health’s facilities already have the capability. Acuity-adaptable beds, for example, have been available since the early 2000s.
Another point of interest Tocco brought up was the fact that COVID-19 has a relatively poor buoyancy, compared to tuberculosis. The virus’s pathogens don’t travel as far by air as tuberculosis, which has been around longer.
“It certainly gets down on surfaces, but it’s not something we worry about circulating significantly throughout the building through the HVAC system as opposed to how TB would,” Tocco said.
An acuity-adaptable room still must be able to keep patients safe from contracting the virus. The room certainly has to be large enough, but Tocco added hospitals have to be mindful of whether services like electrical and medical gas can handle the additional load.
“Generally, the way things are engineered, that’s not an issue. But it’s something you want to check to make certain; if you had to take advantage of two patients being fed both medical gas systems and electrical, that the capability is there,” he said.
Diekema Hamann has received several inquiries from hospitals since COVID-19 broke out about what the firm could do with their mechanical systems to prevent the spread of the virus. Dickerson said older hospital buildings present more of a challenge to update.
“For the first time I can remember, we started looking at making windows operable so we can exhaust directly to the outside, because for the past umpteen years, we’ve been making all the windows fixed windows,” Dickerson said.
Dickerson also saw another instance where a hospital chose to leave IV pumps outside of the patient’s room in the corridor, so the nurses wouldn’t have to go into the patient’s room and increase their risk of exposure to the virus.
“COVID is to hospital design as 9-11 is to airport design,” Dickerson said. “I think it will dramatically change at least how we look at new facilities in the future, especially ways to plan for surges and adapt existing spaces.”