Description

In Spring 2020, the German hospital sector seemed to be faring quite well compared with other countries. Of the 28,000 intensive care beds already available nationwide, 20,000 were equipped with ventilators and overall, only about 70 to 80% were occupied. In addition, the capacity could be increased to 40,000 beds and 30,000 ventilators within a few weeks, for example by postponing less urgent operations, relocating them to out-of-hospital facilities or converting existing buildings, as happened at Berlin’s Charité University Hospital, where an existing modular building that had been used during the conversion of the high-rise wards was rapidly converted into a makeshift intensive care unit. The most problematic aspect of this and other similar solutions was less an architectural one than one of obtaining the necessary medical technology in a market in which supplies of even simple connectors had dried up. Spectacular headlines abounded that seemed almost outlandish in the context of the otherwise long-term planning of hospital facilities: a 1,000-bed hospital built in China in only ten days, a 4,000 bed NHS crisis centre in a London exhibition hall in nine days, and even in Berlin, with its painfully protracted BER airport realisation, a 500-bed corona care centre was built in an exhibition centre on Jafféstraße within four weeks.

However, the return to “regular operation with optional pandemic capability” may pose even greater challenges for hospitals than the short-term switch to crisis mode. This is because the DKG (German Hospital Federation) has recommended that at least 20% of intensive care beds with ventilators remain free with the option to expand capacity within 72 hours.

So, although Germany was faring well, the corona crisis has revealed both structural weaknesses as well as health policy issues. Neither can be resolved through architectural means. The debate that arose following the publishing of the Bertelsmann Foundation study on hospital over-capacity in Germany last autumn has taken on a new dimension in light of the corona crisis. Critics of the study see their standpoint confirmed but the health economist Reinhard Busse argues that the crisis confirms the findings of the study: reducing surplus capacity, bundling expertise in a more structured manner and distributing staff better to fewer hospitals could have made it possible to respond even more efficiently to the crisis. As Busse argues, if it is called a hospital, it should really be a hospital: the study suggested reducing the number of medical facilities that have made little to no contribution to overcoming the crisis as they lack intensive care facilities and corresponding staff.

These problems – staff shortages, procurement problems and a lack of networking – are primarily health policy issues and only indirectly architectural problems. Of greater interest to architects is where the weak points in the design and architecture of hospitals lie, and what interventions may be in store for hospital construction and design?

The corona crisis has made infection control a key focal area of hospital planning. This ties in directly with structural means of infection prevention, the most obvious form of which is the switch to single-bed rooms, an aspect we as authors have long supported. Has the time finally come to establish the single room as the gold standard in Germany, as is already the case in other countries such as the Netherlands, Norway or Denmark, where some new buildings contain only single-bed rooms? The advantages in the event of a pandemic are obvious: single occupancy rooms contribute significantly to preventing infection rates. While this has been proven for intensive care units, the results of studies of normal wards have been less conclusive. Here the need for single rooms is best justified by the opposite case.[1] Other advantages include more peace and quiet, better privacy when talking to relatives or during ward rounds, as well as the possibility to conduct smaller examinations in the room. Until now, however, the implementation of more single rooms has fallen victim to greater construction and running costs as well as increased space requirements. The KARMIN research project by the Technical University of Braunschweig focused on the hygienic optimisation of two-bed rooms, including adequate bed spacing and hygiene-friendly furniture. At the Charité, too, experiments are already being conducted on how two beds can be placed in a 24 m² room with hygiene-compatible spacing.

Rapid responsiveness and flexible deployment of space and facilities were demanded of hospitals, especially at the beginning of the crisis. But how much flexibility is actually possible in hospital construction? Is it possible to design a building that can adapt dynamically to temporary crises without significantly restricting its general operation? For decades, hospitals have been planned down to the last millimetre, optimised to the minimum size and rationalised to remove everything that does not serve a specific function. Today, hospitals are painfully away of the limitations this brings. They literally lack the air to breathe, the space to observe necessary distances, to offer alternative areas and to build extensions. Space that does not serve a dedicated function will no doubt still be hard to justify in hospital construction. However, corona has provided a new argument for defending their usefulness. Similarly, the idea of multifunctional room modules also plays a key role in discussions on flexibility. The concept of a “hospital on command” assembled from prefabricated universal modules for use in any location now seems quite plausible against the background of the pandemic.

Corona will also contribute considerably to accelerating the digitalisation of German healthcare. Where robotics and the transfer of patient data are concerned, quick action rather than German caution is now required. The Save Concept[2] in Berlin developed by the Charité already employs 25 robots on doctors’ rounds. Experts were able to accompany the robots on their rounds in the participating hospitals with the aim of ensuring the best possible care for patients while also exchanging specialist knowledge. Nevertheless, it is hard to imagine autonomously controlled robotic colleagues populating hospital corridors any time soon. What is certain is that these processes must be accompanied by architects and that this could entail a new concept of digital accessibility along with new standards for corridor widths, spacing and movement areas around patient beds.

The heightened concern for hygiene and infection prevention does, however, risk neglecting the demand for open and inviting hospital environments that promote communication. Infection control entails separation and segregation and infected people need to be isolated, as do risk groups. Hospitals have drastically tightened rules for visitors and accompanying persons. Medical and nursing staff who work on Covid-19 wards are likewise subject to additional risks. A major challenge for the future will be to find a balance between maximum protection against infection and isolation on the one hand, and creating life-affirming, supportive atmospheres for patients and staff. A first step would be to allow even infectious patients access to outside areas through patient gardens, terraces or balconies. Common rooms and staff rooms could be made large enough for several relatives or several colleagues to occupy them at the same time while maintaining the necessary distance to one another. The crisis has also raised awareness of preventative approaches in health care because alongside older people, it is people who already have other health issues, such as obesity, who are at most risk. Some of these can be traced back to their lifestyle and, as such, corona is not just a problem for hospitals but also for preventive health care, and in turn for urban planning as a whole. Unfortunately, the current protests against lockdown measures show how challenging it is to enforce prevention. Covid-19 is characterised by its “non-existence” and is therefore more difficult to grasp emotionally and to quantify socio-economically. What is quantifiable, however, are the losses that hospitals are currently incurring due to a lack of revenue. Some of the measures outlined above will therefore be difficult to implement. Despite this, the hope remains that the German hospital construction section can turn this crisis into an opportunity.

Originally published in Bauwelt 15.2020, pp. 48-51, abridged and edited for Building Types online, translated by Julian Reisenberger

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