How can outpatient care centers flex to meet surges in patient volume?
My colleague, Noelia Bitar, and I share six ideas to prepare outpatient care centers for future pandemics.
The number of outpatient centers has increased dramatically in recent years, but as scheduled appointments were canceled during the coronavirus, this valuable real estate stood empty. Ambulatory centers already have basic healthcare infrastructure in place, they potentially could flex to accommodate an inpatient surge. However, many of these facilities were designed to meet only the minimum requirements of current codes — like the FGI Guidelines, which establishes national standards for the design and construction of healthcare facilities — and as a result, their ability to be adapted for inpatient care is limited.
As we think about building new ambulatory care spaces, a few design considerations, above and beyond code minimums, could make it easier for these facilities to adapt. Given funding constraints, it may be challenging to incorporate all of these features into every ambulatory care setting however these are some of the options a health system might consider:
1. Build public area spaces that allow for easy conversions.
If utilized during a surge event, outpatient space would transition from opening only during a set number of hours to a 24/7 service, which would require an increase in staff on all shifts. It would also require additional support areas. These spaces could be designed so lobbies can be converted for triage (screening, testing, queuing, etc.) and patient waiting areas converted into “team work areas” where team workstations, staff amenities (lockers, lounges) and clinical support services can be located outside of patient areas that might be required to be isolated. The code currently requires waiting areas to have a ratio of 1.5 to 2 chairs per patient care room, but it does not specify a square footage per chair; we find that 25 square feet per chair is a good factor for providing additional future space flexibility in waiting areas.
2. Design exam rooms to adapt to observation or inpatient care needs.
a. Room size: The minimum clear floor area required for patient exam rooms per the guidelines is 80sf, but as we design for the future, we could see a shift to enable stretchers to be used in these rooms. Taking into account the appropriate clearances that might be required, 120 square feet is a more appropriate minimum, and sometimes 140 square feet for multidisciplinary team care.
b. Room infrastructure: Medical gases such as oxygen and vacuum could be included in at least some exam rooms, even though the code does not require medical gases in a standard exam room. Telehealth is important not only for virtual visits and expanding access to care but also for helping to reduce exposure to contagion for both patients and staff. It would be beneficial to integrate technology and design that supports telehealth or teleconsults into exam rooms. While the outpatient guidelines offer dedicated spaces where telemedicine could take place, such as a bay, cubicle or room, including it in every exam room would provide additional support.
c. Other exam room considerations:
Monitors with fixed cameras or mobile carts for telehealth and remote consults to be able to remotely view and communicate with the patient (and for families)
Television for patient distraction and education
Communication tools, including “nurse-call” that is voice-activated (the current code does not require nurse call devices in exam rooms)
d. Larger door openings: 48” could be the new norm for the exam room and all patient areas — even though door openings serving occupiable spaces are usually a minimum clear width of 34″, or 41.5″ where stretchers are used, and 4′-door openings are typically only required in the path of travel to public areas and in areas where care will be provided for patients of size. Using sliding doors or double-leafed doors could accommodate a wider opening without impacting the design of the room.
e. Privacy: Even though an exam room, by code, requires privacy for patient consultation, integrating a transparent material like a narrow light or half window with integral blinds would allow it to flex into an observation room, which by code requires patient visibility. Sliding glass doors with a translucent film could be used to maintain privacy while providing light into the corridors during normal exam-room use, but the film could easily be removed and allow for transparent glass, if the room needed to flex for observation.
3. Plan for an isolation zone within outpatient care areas.
An entire floor or section of an ambulatory care floor could be designed to become a negative pressure area. Rooms would need to identified for transforming into donning/doffing PPEs, and the floor plan could adapt to a one-way entry and exit flow.
Similarly, while Airborne Infection Isolation (AII) exam rooms are only required in specific programmatic ambulatory needs, having the option to accommodate a patient who has screened positive for an airborne infection may be advantageous in the surge response plan. A minimum number of AII exam rooms could be required, along with an adjacent room or space to serve as an ante room or vestibule. And don’t forget that patient isolation can function at multiple scales.
4. Expand corridor widths to allow multiple flows.
Although outpatient guidelines only require 6′ corridors in areas where there is use for stretcher transport, if corridor widths were required to be a minimum of 6′ throughout, they could accommodate stretchers and other circulation needs, and support PPE carts outside rooms, EVS cart parking, patient transportation etc.
5. Choose the soiled workroom over the soiled holding room.
Most outpatient general facilities only require soiled holding rooms in exam areas, as they are only used for temporary storage of soiled materials and supplies — as opposed to more intensive soiled workrooms, which include additional plumbing and space in which staff can work. However, choosing to include the soiled workroom in outpatient settings will also allow for cleaning or disposal of soiled items with the multiple sinks required by code for inpatient care.
6. Add redundancy in infrastructure.
Including additional electrical power in public areas like waiting rooms and exam rooms makes it possible to support additional equipment loads such as physiological monitoring, mobile diagnostic equipment, emergency power and more. Likewise, HVAC systems ideally would be flexible enough to accommodate 24×7 patient care, additional cooling for increased staffing, thermostats in each exam room or the modest increase in air changes per hour — from 4 to 6 — required by code for inpatient settings.
Many of these features will entail additional costs (power, HVAC, corridor widths etc). However, there are also significant costs associated with leaving an ambulatory care space idle because it is unable to meet unexpected care needs like the Covid-19 pandemic. Some additional upfront investment may be necessary but doing so will ensure that these centers will be ready to flex when the next emergency arises.