Flexible hospital design key for future pandemics

The study we undertook aimed to identify important infrastructural adaptations that were undertaken by the hospitals in question in response to increasing number of COVID-19 patient admissions during the surge phase of the pandemic. We studied 257 hospitals that responded to a questionnaire about the infrastructural adaptations they made during the pandemic — in areas ranging from facilities management, management of medical equipment, and human resources management, to management of beds for emergency COVID-19 patients. We also questioned them about the hospital features and clinical activities for both non-COVID and COVID-19 patients between 2019 and 2020.

Statistical analysis

We statistically analysed the important explanatory variables for increasing the number of COVID-19 patient admissions, using a multivariate logistic model, followed by a stepwise procedure. The possible explanatory variables were selected beforehand by univariate analysis. The accommodation capacity was defined as the number of admissions of COVID-19 patients adjusted by the number of nurses.

Three infrastructural adaptations emerged as important explanatory variables for increasing the accommodation capacity for COVID-19 patients: mandatory securing of beds for COVID-19 patients (odds ratio [OR] 10.24, 95% confidence interval [CI] 4.79-21.85, P<0.000), additional purchase of ventilators (OR 2.46, 95%CI 1.28-4.73, P=0.007), and installation of negative pressure rooms
(OR 3.84, 95%CI 1.68-8.78, P=0.001). As regards infection clusters, a large increase in the accommodation capacity was selected as a single explanatory variable (OR 9.45, 95%CI 3.16-28.24, P=0.00006).

Conclusions based on the survey

The survey results showed that effective management of the facilities, patient beds, and medical equipment, were all key to the ability to secure sufficient accommodation for COVID-19 patients during the pandemic’s surge phase. The results also indicated that a large rise in COVID-19 patient admissions might have led to infection clusters regardless of the precautions taken. From the results we concluded that the ability to promptly secure accommodation capacity for COVID-19 patients is commensurate with the degree of infection risk. A flexible design incorporated into infection control could be an effective solution in preparedness for a future pandemic.

Healthcare professionals have learned many invaluable lessons from the COVID-19 pandemic — among them the importance of a range of anti-pandemic measures to prevent coronavirus transmission, such as standard precautions, isolation and surveillance of infected patients, control of human behaviour, and vaccination.

When considering infrastructural adaptations, improving ventilation in hospital buildings is one of the most important ways to mitigate the spread of aerosol infection. However, the rapid architectural renovations often needed to achieve this are generally not feasible because they take considerable time and money. Other anti-pandemic measures should be considered as practical infrastructural adaptations, particularly during the early phase of the pandemic, when it is crucial to promptly secure sufficient accommodation capacity for emergent infected patients.

We surveyed the infrastructural adaptations against the COVID-19 pandemic during its acute phase. The responses to the questionnaire on anti-pandemic measures were analysed statistically using relevant clinical data to identify the key factors related to accommodating the explosion in infected patients

Materials and methods


Survey of infrastructural adaptations

We conducted a nationwide survey on the measures taken by hospitals in Japan to address the COVID-19 pandemic, sending a questionnaire to the directors of 4,825 hospitals with 100 or more beds. In the questionnaire, we asked what anti-pandemic measures the hospitals had implemented to mitigate the spread of Coronavirus infection between 2019 and 2020. We also asked about the hospital features and clinical activities, such as the number of beds, healthcare staff, non-COVID patient admissions, and COVID-19 patient admissions. The answers were collected online using the Google Forms application.

For analysis, we calculated the increase in COVID-19 patient admissions between 2019 and 2020. As the total number of admissions depends on the hospital size, the calculated results were adjusted by the number of nurses. We used the equation below to obtain an objective value of increased accommodation capacity for COVID-19 patients.

= (Adjusted number of COVID-19 patient admissions in 2020)

− (Adjusted number of COVID-19 patient admissions in 2019)

= Increased accommodation capacity for COVID-19 patients

Statistical analysis

We statistically analysed the questionnaire responses to identify significant explanatory variables for increasing the accommodation capacity for COVID-19 patients. Statistical analysis was performed using both univariate and multivariate analyses. To assess candidate explanatory variables for an increase in COVID-19 patient admissions, Pearson’s chi-squared test for 2 x 2 tables was used initially to identify variables possibly correlated with increased accommodation capacity for COVID-19 patients. Fisher’s exact test was used for small samples. Relevant variables with P<0.2 were selected for inclusion in the next step of multivariate analysis.

The logistic model was used for multivariate analysis with odds ratio as a measure of association. The increased accommodation capacity was classified into categorical variables. When P>0.1, the increase was considered large. We used a stepwise procedure to select important variables relating to increased accommodation capacity for COVID-19 patients using the minimal Bayesian information criterion. We used R software (version 4.4.2, the R Foundation for Statistical Computing Platform) for statistical analysis.

Candidate explanatory variables

In this particular study, we only investigated the infrastructural adaptations. Clinical preventative practices such as standard precautions were excluded from candidate variables possibly related to increasing the accommodation capacity. The following variables were included in the univariate analysis: employment of infectious disease specialists, infection control nurses, and infection control doctors, installation of an ICU department, isolation rooms, and negative pressure patient rooms, remodelling general wards associated with improved air ventilation, operational changes in patient beds, mandatory securing of COVID beds, ward closures due to infection ‘clusters’, and additional purchase of ventilators, ECMOs, haemodialysis machines, and portable negative pressure systems.

We carried out the same statistical procedures to identify significant variables for the incidence of clusters. We used the aforementioned candidate explanatory variables, except for ward closure due to a cluster, because this variable is closely correlated with the incidence of clusters.

Results

A total of 257 hospitals (5%) responded to the questionnaire. These included 193 with 100-399 beds, 52 with 400-799 beds, and 12 with 800 or more beds. The mean number of admissions of COVID-19 patients was 6.0 in hospitals with 100-399 beds, 4.8 in hospitals with 400-799 beds, and 5.6 in hospitals with 800 or more beds. Hospitals with fewer than 400 beds appeared to play a major role in accepting COVID-19 patients regardless of their disease severity in the earliest phase of the pandemic in 2019 (Table 1).

In the univariate analysis, all candidate explanatory variables were selected for the next multivariate analysis. As a result, the infrastructural adaptations listed in Table 2 were considered candidate explanatory variables.

Significant explanatory variables for increased accommodation capacity for COVID-19 patients (Fig. 1)

In the logistic analysis, three infrastructural adaptations emerged as important explanatory variables for increasing the accommodation capacity for COVID-19 (Table 3). Remodelling a general ward to an infection ward associated with improved air ventilation may have been effective for moderately increased accommodation capacity without infection risk. However, it was not shown to be a statistically significant variable.

Significant explanatory variables for incidence of clusters (Fig. 2)

In the univariate analysis for clusters, employment of infection disease specialists was excluded from the possible explanatory variables. According to the multivariate analysis, a large increase in the accommodation capacity for COVID-19 patients was selected as a single explanatory variable (Table 4).

Three infrastructural adaptations emerged as important explanatory variables for increasing the accommodation capacity for COVID-19 patients; mandatory securing of beds for COVID-19 patients (odds ratio [OR] 10.24, 95% confidence interval [CI] 4.79-21.85, P<0.000), additional purchase of ventilators (OR 2.46, 95%CI 1.28-4.73, P=0.007), and installation of negative pressure rooms
(OR 3.84, 95%CI 1.68-8.78, P=0.001). As regards infection clusters, a large increase in the accommodation capacity was selected as a single explanatory variable (OR 9.45, 95%CI 3.16-28.24, P=0.00006).

Discussion

There have been many reports that hospitals had to accommodate an enormous number of infected patients beyond their capacity during the surge phase of the COVID-19 pandemic. Since most hospitals cannot afford to enlarge their accommodation space immediately, managing the already existing beds should have been key to this emergent situation.

Besides clinical preventive practices, there were several options to manage beds for COVID-19 patients, such as remodelling wards by improving the air ventilation in hospital rooms, changing bed use, increasing the number of isolation rooms, increasing the medical equipment, introducing portable negative pressure systems, and employing specialist healthcare staff. However, multivariate analysis showed that none of those measures was effective for receiving emergent infected patients. Our results indicated that mandatorily securing beds for COVID-19 patients was one of the most effective ways to increase the number of patient admissions (Fig. 3).

Another important finding is that securing sufficient accommodation capacity for COVID-19 patients was not necessarily safe for patients or healthcare staff. Multivariate analysis showed that a large increase in hospital accommodation capacity was a single explanatory variable for the incidence of clusters. It has also been reported that COVID-19 patient admissions are associated with a psychological burden on healthcare staff.¹ It is thus essential to balance the acute increase in admissions of COVID-19 patients and the associated infection risk.

Speed of response

Speed is another important factor in the responses to the pandemic, particularly during the surge phase. To this aim, facilities should have been robust and adaptable beforehand. Infection control measures need to be incorporated into architectural and structural design, with planning for versatile spaces with convertible walls and floors to ensure that the facility can accommodate as many infected patients as possible with minimal renovations during the surge phase of a pandemic. A flexible layout can enable hospitals to transform quickly from routine care areas to areas suitable for emergency response while providing safe patient isolation, where HVAC systems maintain air quality and filter out contaminants.^2,3

Improved readiness

A flexible design would also allow us to be ready for future pandemics. Although we cannot predict the exact nature of the next pandemic, future-focused layouts should include clinical zones that allow easy expansion, supporting shifts in service delivery and patient demographics. For pandemic preparedness, it is imperative to create hospital buildings that can accommodate a sudden increase in infected patients with minimal expense and disruption. Large organised structural bays with adaptable walls and floors could enable hospitals to ensure the admission of infected patients with minimal renovations once a pandemic occurs.

During the last pandemic, hospitals used outdoor space in the hospital premises by converting it to temporary areas to accommodate medical activities. This approach also assisted with the shortage of beds and treatment rooms, and heavy traffic in the earliest stage of the pandemic.⁴

Conclusions

Promptly securing accommodation capacity for COVID-19 patients must be commensurate with infection risk. We should incorporate infection control into the architectural design of hospitals to ensure a speedy a response to events such as a pandemic. A flexible design could be an effective solution in preparedness for future pandemics.

Acknowledgement

• This work was supported by MHLW Special Research Programme Grant Number JPMH20CA2046.

References

1 Yasuhara H, Atarashi H, Nakajima A, Takashina M. Remodelling hospital facilities during COVID. IFHE Digest 2024; 33-36.

2 Humphreys H, Vos M, Presterl E, Hell M. Greater attention to flexible hospital designs and ventilated clinical facilities are pre-requisite for coping with the next airborne pandemic. CMI 2023; 29:1229-31.

3 Van Heel L, Pretelt M, Herweijer M, Van Oel C. Perspectives on assessing the flexibility of hospitals for crisis mode operations: Lessons from the COVID-19 pandemic in the Netherlands. HERD 2024: 17(1):34-48

4 Ma M, Adeney M, Long H. Functional settings of hospital outdoor spaces and the perceptions from public and hospital occupant during COVID-19. Healthcare 2021; 9(11), 1534. Available from: https://doi.org/10.3390/healthcare9111534