With the outbreaks of Severe Acute Respiratory Syndrome (SARS) in 2003 and Middle East Respiratory Syndrome (MERS) in 2015, it was only matter of time before another infectious disease appeared on our doorstep. COVID-19 arrived even sooner than expected. As the saying goes, Korea ‘locked the stable door after the horse has bolted’, and although SARS and MERS left a lot of damage in their wake those experiences proved instructive, forcing the authorities to recognise the importance of improving medical facilities.
In Canada, 75% of SARS transmissions occurred within hospitals. In Korea, MERS brought a heightened awareness of the role droplets play in spreading disease, leading to legislative reform on regulations regarding medical facilities such as patient rooms, intensive care units and emergency wards. What recent clusters of COVID-19 infection have made clear, however, is that no medical facility or place of public gathering is safe from COVID-19. The lessons learned from the past have provisioned us with what in all good hope is a successful quarantine system which has limited the spread of the coronavirus, but suffice to say that the prospects of another spike in cases is extremely concerning and not only for medical professionals and the vulnerable.
Design Requirements for Medical Facilities
Medical spaces are visited by sick people, whose needs vary from slight, in the case of common colds, to severe, those on transplant lists or undergoing chemotherapy. Many people fully recover following treatment, but ironically, some become sicker and even die because of the care given to them, from secondary infections or accidents. Thus, architectural design for healthcare spaces must be based on objective scientific facts, instead of the architect’s individual experiences. With this in mind, the American non-profit organization, the Center for Health Design, administers Evidence-Based Design Accreditation and Certification (EDAC) in order to develop processes that accredit architects, healthcare executives, technicians, and researchers as practicing data-driven design. The Korean equivalent is fulfilled by the Medical Planner, who specialises in the design of medical facilities, and who works closely with healthcare professionals to create safer, healthier healthcare spaces.
For the general public, hospitals are rarely associated with fond memories, but for healthcare workers and staff, for better or for worse, they are everyday spaces and effectively a microcosm of society. Thus, medical spaces must be designed to reflect the needs of patients, medical workers, and other users, as well as consider future changes in the spread of disease and the latest developments in medical equipment and technology.
The Unique Vulnerability of Korean Medical Facilities to Disease Outbreaks
While the patient ward occupies up to 40% of a general hospital’s net square footage, individual patients barely inhabit more than 6.6 square metres - less than half the equivalent space in the UK or Australia. Disease transmission within hospitals has greater implications that those for real estate. Research has found that Korea’s MERS outbreak was exacerbated by secondary infections stemming from failures in initial government responses, a culture of shared hospital rooms, and other individuals accompanying and visiting patients. At the time, Korea’s healthcare system was uniquely susceptible because of the lack of negative pressure rooms, the widespread practice of hiring private caregivers, and a society-wide preference for visiting emergency rooms at large hospitals and subsequently longer stay times. After the MERS crisis, new hospitals were built to include negative pressure rooms, and shared hospital rooms, which in older buildings used to house anywhere from six to ten patients, and were mandated to a maximum of four-person capacity. New rules stipulated that hospital beds had to be spaced a minimum of 1.5m apart, so as to reduce the risk of infection through droplets. But this was difficult to implement in pre-exiting medical facilities. In order to reduce a six-bed hospital room to fit four people, extensions needed to be added to the buildings so as to maintain the total number of hospital beds. I visited a regional rehabilitation hospital in December 2018, when the stay period for the new spacing requirement between patient beds was about to expire. This hospital opted to place one of the beds right in the centre of the room’s pathway, sacrificing patient privacy in the process. In another room, a bed was placed right next to the sink area, presumably putting the patient at greater risk of infection.
COVID-19 outbreaks have thus far occurred in the most vulnerable group homes, such as psychiatric hospitals and assisted living facilities, which assembled people with weakened immune systems and put them at higher risk of infection. Reports suggest that within an enclosed space, an infected individual can infect up to 30-40% of the people there. Though subject to individual variation, psychiatric patients usually remain in hospitals for longer periods than those of other departments. People with dementia record the longest average duration of stay, at 252 days, while other psychiatric disorders closely follow, in the order of schizophrenia, delusional disorders, and Alzheimer’s. Psychiatric patients average a total of 98 days in stay, with 1.6 hospitalisations per year and are generally hospitalised for the long-term. However, many facilities do not offer proper restrooms except for private rooms. This is particularly worrisome because patients in psychiatric wards do not often have proper access to outdoor activities and as a result weakened immune systems. Additionally, they are required to participate along with other patients in programmes such as meals, rehabilitation therapies, and other activities designed to aid in their return to society, further raising their risk of infections over other patients. Psychiatric wards also do not make as frequent use of treatments, and thus have less need for sterilisation and sanitation, and may lack even a dedicated storage for sanitation equipment.
On the other hand, elderly care facilities are different from geriatric hospitals in that the former are bound not by medical law, but the Welfare for the Aged Act. Thus, assisted living facilities are covered by Long-Term Care Insurance, whereas geriatric hospitals fall under the purview of National Health Insurance, which effectively leaves the former unaffected by hospital bed spacing regulations, among other things. Elderly care facilities admit senior patients suffering from dementia, and complications from strokes, and other senile disorders, and assist them with daily living activities, such as eating, and convalescent care. To manage and care for patients with impaired cognitive capacity, these services have to be delivered on a closed and standardised basis. Most rooms are shared by multiple patients - including bathrooms, living rooms, canteens, physical therapy rooms and recreation rooms - which leads to greater risk of a single infection snowballing into an uncontrollable mass outbreak.
An Effective Epidemiological Surveillance System Based On Contact Tracing
During the MERS outbreak, secondary and tertiary transmissions ballooned within hospitals and constituted up to 47% of total cases, highlighting the need to improve epidemiological surveillance systems as well as the culture of hospital visits and physical layout of hospitals. This led to the installation of sliding doors that separated the elevator halls from individual departments, but passageways remain only haphazardly regulated by security personnel.
In Singapore, all visitors entering hospital wards must go through a Speed Gate and are allowed through only on an appointment-basis, which ensures that no one wanders the elevator halls by accident. In addition, passageways for medical professionals are separated from those reserved for patients and visitors. On the other hand, outpatient clinics are made easily accessible via an over-bridge that connects them to shopping centres, which allow for easy trips following hospital visits, and passageways that join them to nearby subway stations. Also, within the hospital grounds shops and restorative gardens make the building attractive to even local residents, unlike Korean hospitals that are considered places to avoid. The outbreak of an infectious disease, such as we are experiencing today, exacerbates this kind of perception. Local residents adamantly oppose the building of assisted living facilities and psychiatric hospitals in their neighbourhoods, arguing that they will reduce their property value.
Since the early 2000s, Korean hospitals have adopted slogans such as ‘patient-centric’, ‘a home away from home’, and ‘hotel-like’ to describe their institutions, and implemented the concept of ‘hospital street’ to turn their outpatient departments into tall, capacious and comfortable spaces. In contrast, other wards such as intensive care units or emergency rooms, at greater risk of infection, were furnished with less less spatial provisions. Furthermore, there are virtually no guidelines that manage standards for less conspicuous spaces that serve to support medical staff or store medical waste and sanitation equipment. Negative pressure rooms quarantine infected patients to protect unaffected individuals. When an infected person is admitted to such a facility, healthcare professionals form teams of two to prepare for unexpected emergencies and wear personal protective equipment (PPE) to enter rooms. After exiting those areas, they must go through another anteroom to change into their regular clothes before they can enter the general wards. Such physical separation in circulation planning is necessary for medical staff to perform at their highest level.
Positive Change Requires Extra Space
The Korean government introduced the Integrated Nursing and Care Service Programme in 2013, to alleviate the financial burden those services place on individual families. Under this policy care can be provided by nurses instead of family members or privately hired caregivers; this may appear beneficial enough, but in fact exacts a heavy cost on nursing staff, who are additionally required to manage a patient’s needs. The new programme makes commensurate demands of hiring more nurses and improvements to their working conditions, but reality has yet to catch up in that regard. Because nurses have been charged with monitoring their patients at close quarters, they need to be stationed further away from their current posts in the centre of the ward to sub-stations that should be created closer to the patients under their watch. But few hospitals have been designed with this extra space in mind, and creating new areas is rarely practicable, which leaves nurses setting up ad hoc desks with computers in the limited corners of 2.4m corridors, leaving a trail of extension cords when power outlets are lacking. Although there are definitely cases that leave room for improvement, the system as a whole is clearly making continuous strides through continued discussion and experience. Under the Integrated Nursing and Care Service Programme, new hospitals are being created with the addition of distinct visiting rooms to control the flow of people coming and going, as well as the aforementioned sub-stations.
For these positive changes to continue, it is necessary for hospitals to reserve additional space in their designs so as to be able to respond to changing demands and policies. It is not possible for these institutions to build an unlimited number of negative pressure rooms. Portable negative pressure chambers for individual patients can serve as a good alternative, whenever the need arises, to prevent possible outbreaks. This is particularly important in order to protect those with vulnerable immune systems, such as newborns and the sick needing critical care. And while it is a relief that a maximum cap of four beds to multi-bed rooms has been put in place, ironically enough, a new law that shared rooms comprise 50~80% of the share of all beds was enforced in January 2020 as a means of reducing the strain on National Health Insurance. Though there will be variations in the ways the policy is affected by bed numbers as regulated by Insurance’s medical fees standards, staffing of nurses and the Integrated Nursing and Care Service Programme, it is important to communicate the importance of private rooms for infection containment. And yet, these are considerations that are difficult to apply to assisted living facilities that do not come under the jurisdiction of medical law.
If infections do occur, patients should ideally be transported to hospitals that specialixe in infectious diseases. But as such hospitals are in limited supply, these individuals are inevitably sent to tertiary or general hospitals. During our present COVID-19 crisis, even examination rooms were filled to full capacity such that even critically ill patients were asked to self-isolate at home. To care for such patients is the responsibility of the public health service. The government must prioritise going a step further from setting up drive-through screening care facilities, to standardising these spaces and collaborating with community health centres and creating modular hospital rooms. These plans require that local health centres be designed with additional space to be able to respond to such changing needs.
Final Recommendations On Creating Healthier Medical Spaces
What constitutes a healthy healthcare space that will allow patients and medical professionals to give and receive care without worry? We design medical spaces in the service of treating and curing patients, but inadvertently employ various toxic chemicals in the construction phase. A healthcare facility runs 24/7 and requires more than twice the energy levels that are demanded from other commercial buildings. Most of them rely on fossil fuel, which leads to pollution that contaminates the air both indoors and outdoors. Additionally, millions of tons of disposable plastic equipment and gloves are disposed every year, potentially adding to factors that cause disease in the community. These are all aspects that deserve close examination.
In April, stringent social distancing measures were put in place, and streets were full of people donning face masks. Playgrounds, however, were filled with rowdy elementary school students who had left their masks strewn around the place, and mothers who watched on as if relieved that at least they were safer outdoors. As with unruly children, infectious diseases can similarly run rapidly out of hand. It’s a sign of some measure of success of Korea’s fight against COVID-19 that social distancing has been relaxed and schools are slowly reopening. But the disease could potentially return at any point, so it would be wise to learn from our past experiences and improve our medical facilities for more advanced needs. We must continue to pay attention and provide an adequate number of private hospital rooms, better control of visitors on an appointment-basis, modular hospital rooms, and the standardisation of screening care facilities.