The impact of the COVID-19 pandemic has pushed the U.S. healthcare system beyond all known limits. Providers have faced and currently face challenges at several different levels, including shortages of personal protective equipment (PPE) supply, changing care protocols, employee burnout, capacity requirements, vaccine protocols, and facility adaptability. Although the variants and proliferation of COVID-19 are still with us, it is appropriate to start recording lessons learned to better understand how planning and design functions can maximize and seamlessly respond to the care needs of a series of crisis events.

The prospective expansion of two emergency inpatient wards (7NT and 8NT) in the North Tower (7NT and 8NT) of the Milwaukee Froedtert Hospital, a major academic medical center affiliated to the Medical College of Wisconsin, illustrates the importance of maximizing design adaptability to accommodate various diseases. The type of acute care patient population, including those experiencing COVID-19.

The project was completed in 2013, and its goal was to create a hospital environment for future or potential patients, not necessarily the current patients planned for the space. With the aging of the population and the shift in providing care in outpatient or home settings, the acuity of patients in need of hospitalization continues to increase. Recognizing that healthcare organizations are uncertain about how many ICUs and emergency care beds will be needed in the future, the project team tried to create an emergency care environment that can be easily converted to ICU capacity. Little did they know that a transition would be needed in six years.

getting Started
In the pre-design phase of the project, HGA Architects and Engineers (Milwaukee) collaborated with the leadership of Froedtert Hospital to form a strong interdisciplinary project team including nursing staff, doctors, residents, support staff, therapists, patients and family members , As well as design researchers, engineers, architects and construction managers.

The team participated in a number of lean exercises during user group meetings, such as spatial adjacency graphs (that is, the team organizes the space as needed), speed dating (that is, the team asks each other questions about its process), and information gathering (that is, the team investigates the interest Theme) in order to derive the design and operating characteristics required to create an adaptable ward and ward design. In addition, the researchers of the design team spent a week on the existing unit of North Tower (3NT), collecting baseline data through interviews and shadows with patients and employees.

This data helps to formulate the project vision stated in the framework of the Critical Quality (CtQ) standard, a lean Six Sigma concept used to identify environmental or operational requirements that are critical to achieving quality processes or experiencing results. For this project, the quality results categories include patient satisfaction, patient safety, doctor/staff satisfaction, home-centered care, efficiency, flow, and utilization of supplies, medications, equipment, and bed sheets. Once the CtQ indicators are established for each quality result, they are communicated to the project team to help design and operational decisions. In addition, these metrics are also used to evaluate prototypes and models during the design process.

Some final design solutions related to the CtQ standard include:

• Patient safety: Expand the ward to be large enough to handle equipment for high-risk patients, patient lifts in each room, accommodation for obese patients, and space for caregivers to perform basic nursing functions. It is also established to maximize the visibility of patients from decentralized mapping stations, and can view the situation of each ward.
• Family-centered care: Including independent family space in the ward, overnight accommodation, and various family comfort zones outside the room and the ward.
• Movement and use of supplies, medicines, equipment and bed sheets: Using a decentralized approach, key patient care items, including medications, supplies, bed sheets, and PPE can be accessed close to the work area of ??the nurse server outside each ward. Priority is also given to the distance between equipment niches, pharmacies and staff toilets and wards.
• Doctor satisfaction: The strategy includes a spacious space to handle groups of 15-20 people; a space in the ward for the entire team to participate in discussions; and gathering in an alcove outside the ward without blocking the corridor.
• Employee satisfaction: There is enough room for employees to collaborate, educate and breathe in the unit, and can use natural light.
• Patient satisfaction: In order to solve the problem of noise reduction, the team designated to cancel the central nurse station and use rubber flooring and soundproof artwork in the corridors.
• efficient: Planning for flexibility, the environment will need to adapt to increasing acuity (for example, acuity adaptability).

Measure improvement
Several months after the construction of the newly designed 7NT and 8NT units were completed and put into use, the project team hoped to conduct a post-occupancy assessment to understand the full impact of their design decisions. Similar qualitative and quantitative methods used to collect 3NT baseline data in the early pre-design phase were also used to collect 8NT post-occupancy data for comparison. As a result, the evaluation showed a significant increase in staff efficiency, as the nurses’ business trips were reduced by 6%, which in turn was directly related to a 6% increase in the time spent in the ward. Locating supply servers and mapping stations outside each ward, and creating two semi-dispersed pharmacies and nutrition locations, helps shorten travel distances. Each day nurse needs approximately 36 minutes to change, which is equivalent to approximately two full-time employees or a salary cost of US$182,097 per year. Another example of a return on investment is a 35% reduction in the fall rate (or a 5.75 reduction in the number of reported falls each year), which is estimated to save $53,667 in annual costs. The reason for the decrease is the increase in the time the nurse spends in the room and the increased visibility of the patient through the decentralized mapping station located outside each ward, which allows continuous passive monitoring of the patient through the observation window.

Considering only the four employee indicators—efficiency, turnover, recruitment, and staffing—a total annual cost savings of $526,272 after moving in. Similarly, improvements in only the three patient indicators of falls, pressure ulcers, and length of stay (LOS) are estimated to save $371,968.00 per year. The estimated annual total return on investment is US$898,240.00, and it only takes seven years to recover the one-time construction cost of a new 24-bed adaptive inpatient ward of US$6.25 million. Soon after occupying the new space, these units became one of the best performing units among the other 27 units in the hospital. Obviously, planning and design features lead to high-performance emergency rooms.

Adaptable case
Since moving in in 2013, both units have been flexibly adjusted many times in the type of patient care, and they have been refurbished and cost the least. The first transition occurred in 2019, when the original staff and emergency surgery patient population moved to another area of ??the hospital. This led to the conversion of both units into acute care units for medical patients. The second transition occurred in the spring of 2020, when the number of COVID-19 in southeastern Wisconsin began to increase. At that time, approximately 40% to 50% of hospitalized COVID-19 patients required ICU-level care, and another 50% to 60% required acute care. In the months before the pandemic, the average hospital occupancy rate had reached 90% to 95% (similar to other parts of the state), and only 17% of hospital beds were ICU-level. Therefore, it was decided to convert the 8NT unit to treat COVID-19 positive acute care patients and use the 7NT unit as a non-COVID-19 ICU unit.

Since both units are designed as adaptable rooms, the healthcare system can seamlessly adapt to these changing needs. For example, in the ward, the private bathroom provides infection control measures. In addition, there is a gap of 4 to 5 feet around the bed, which makes it easy to transfer the patient to a stretcher and/or multiple large equipment in the room at once. The bed gap also allows two beds to be placed in the ward to cope with the surge in traffic. Two sets of medical gases on either side of the ceiling wall make double rooms possible, although this is not required.

In terms of nursing staff, the nursing team is dispersed to the decentralized nurse station closer to the designated ward (the ward and recessed niches can be seen from the window) instead of at the central nurse station. This fits better with the social distancing protocol recommended by the Centers for Disease Control and Prevention, while also helping staff get closer to the patient’s bedside. The extra space outside the ward also leaves enough room for patient care equipment, so staff can adjust settings without having to enter the room and use more PPE.

When 7NT transitioned to accommodate ICU patients, some features that were not originally included in the design were also added or modified. Specifically, an equipment storage room was added to accommodate ICU equipment, including additional patient monitoring equipment, ventilators, and infusion pumps/modules; additional monitors were installed at each decentralized mapping station to enable continuous monitoring of high-risk Patient: The door of the ward was modified into a larger glass cut to improve the visibility of patients and monitors in the corridor. In total, the cost of adding or modifying design features is approximately $40,000, allowing the design to be adjusted relatively quickly and seamlessly.

Continuous performance
Despite the transition to different levels of care and patient groups, these two departments continue to perform very well, with many improvements in patient care outcomes, including a decline in hospital-acquired infections/conditions and higher nurse sensitivity quality indicators and patient satisfaction . In addition, the feedback from the staff is that the converted ICU environment is functioning well.Although the lasting impact of this epidemic will be a discussion point for the industry in planning and designing future hospitals and clinics, the lessons learned from such projects will help document and provide insights on how to predict the next crisis event

Dr. Kara Freihoefer is HGA (Milwaukee). You can contact her at [email protected]. Sarah Cypher, DNP, RN, NE-BC, is the director of nursing at Froedtert and the medical school Wisconsin-Frodet Hospital (Milwaukee). You can contact her at [email protected].