by Theresa Walsh Giarrusso
With U.S. COVID-19 hospitalizations jumping an estimated 46% from a month ago, strained medical facilities are looking for strategies to meet the overwhelming demand on clinic space and staff.
West Coast medical facilities managers tangled with these same threats back in the spring (and more with wildfires and smoke quickly following) and have much advice to offer their colleagues now. In September, VirtualCast 1 Hour interviewed four of the top West Coast medical real estate executives to find out exactly what they faced and how they coped. The full episodes, “Recalibrating Medical Facilities Amid Disasters,” A Special 2-Part Report from California and Oregon,” are FREE for healthcare provider employees & AMFP members
In this session, Kerrie Bartel-Christensen, Vice President of Real Estate Strategy and Operations for the Oregon region, Providence Health, sat down with Jon Inman, Principal, Mazzetti, President, AMFP Northern California Chapter, to discuss her strategies in Oregon. (You’ll find more discussions with other regional healthcare leaders here.)
This discussion has been edited to the essence of the conversation and is just highlights. Healthcare provider employees and AMFP members can watch full episodes for free at this link.
Jon: Kerrie, tell us a little about your position and about Providence St. Joseph?
Kerrie: I am now the Vice President of Real Estate Strategy and Operations for the Oregon region, but that is new. Providence St. Joseph Health is an integrated health system with facilities up and down the west coast. I believe we have 51 hospitals and hundreds of medical office buildings in Oregon, which is the portfolio I am responsible for. We have eight hospitals and roughly 200 outpatient buildings that range from physicians’ offices to urgent cares to administrative locations as well. Real Estate Strategy and Operations is the group that oversees the built environment. So, that is real estate designing, construction, facility engineering, environmental services, and then a smattering of other things that go in with environmental services like laundry, patient transport, and conference rooms here and there.
Jon: Just focusing on the hospitals, how have they been impacted by the wildfires and how has that kind of built environment been able to help you or hinder managing patient care?
Kerrie: In Oregon, most of the fire danger is over unlike our friends down in Northern California, where everything is blazed up again. We had one of our hospitals that we did have to evacuate. They had only gotten to a level two, but they did have some higher acuity patients that are hard to place. So, we went ahead and pulled the trigger and evacuated that hospital. They stayed evacuated for a few days. We did not quit operations altogether. When the fire backed down to a level one, we were able to come back. We had a great partnership with the National Guard in helping us evacuate. I got to say that one of the hardest things to combat with the smoke and the dangerous air quality is the smell of smoke.
We used the MERV and HEPA filters on our ministries. For COVID, we were trying to flush everything with as much fresh air as possible. When the wildfires came, we had to back everything down. We were trying to draw only 10% outside air, and the filters do a great job in filtering out the dangerous particles. But you cannot filter out the smoke smell. We did a lot of monitoring for carbon monoxide so that we were not at risk of too little fresh air.
Being in an integrated department, it has probably only been about a year and a half that Real Estate and Design and Construction has been integrated with Facilities and Environmental Services. So, they used to all be separate departments. We came together, I want to say, in April of 2019. That created us a tremendous amount of flexibility and strength. We are pulling on contractor partners and vendor partners in a coordinated way. So, I’ve got to say that was probably one of our organizational strengths, which is the fact that we are integrated so we could move it in a coordinated fashion.
Jon: From the newer buildings, older buildings, were there times that you were just having such a difficult time like the smoke management?
Kerrie: Absolutely. We had done a large investment in our St. Vincent Hospital that probably just wrapped up about a year ago. In that investment, we modernized a lot of the equipment. So, the facilities team over there can do a lot of air handling adjustments remotely. Our Providence Portland Hospital, we had that from circa 1940 to 2006. That building is a manual process for the facilities team to adjust those intakes.
Jon: Switching over to your Clinical Outpatient Medical Office buildings, what were some of the things that you ran into there?
Kerrie: Some of them were even much closer to the fires. Some of them, we were not even sure if they were standing. We are both landlord and a tenant and owner. So, we have a mix in our real estate portfolio. From the clinic perspective, the infrastructure and set up is so much different. They are just shared there. Most of the time you do not get the ability to create those kind of isolation points or negative rooms. So, it was much harder to create spaces that did not have the penetration of the smokes. … So, a lot of our clinics, once the air quality was too dangerous, we just closed it. They had to stay closed until we could get the air quality and the fresh air flushed back into the building. … In drive-through testing, we had to scramble and move that indoors.
Jon: What was your approach for your facilities in the early stages of dealing with COVID? What have you learned over time on how your buildings can help you or how they kind of impacted operations?
Kerrie: It was so critical. In King County, when the virus first started picking up in Seattle, we have a hospital out there that had been dealing with it. Our medical team and our infection prevention specialist were able to get on the phone with the physicians in Wuhan, China, that had been dealing with it. They had learned as they went through the pandemic. It was just amazing to us that they were able to test surfaces to see that COVID is on the nurse’s station, and it sticks to the carts coming through the corridor, and it sticks to people’s shoes. At that point, we were not even testing people yet. The fact that they could test surfaces kind of blew our minds. But one of the things that they imparted to us is that you need to cohort your patients. What they meant by that was on a nursing floor, you cannot have a COVID patient in a room and then have a non-COVID patient in the next room. Even though those rooms are safe, with people and staff and equipment traveling through the same corridors, the virus spreads.
Early in the pandemic when we were not doing social distancing yet, when the doubling time of the virus was high, the viral load in the community was high, we were thinking that things were going to get bad. We started to prepare for field hospitals and alternate care spaces, how do we take vacant spaces and turn it into a functioning hospital quickly, how can we build respirators, how can we build ventilators, and how we are going to support this community? But that cooperation turned out to be so incredibly valuable. Instead of having a sick patient and then somebody in for cardiac, you had to make an area of the hospital where you were like, “This section is our COVID section. In this section, people might have COVID, we do not know yet, but they will either rule into the COVID or rule out into the non-infectious population.” You must build a set up for your air handling equipment for that as well. So, your Environmental Services team needs to know where you have got your Hot Zones. The red zone is kind of the hot infectious zone whereas the green zone is the less infectious.
Your vital services staff needs to know, your cleaning protocols must be on point, you must make sure that you can create those negative pressure areas, and we are constantly learning. I think that every day, we learn something new about the virus that impacted the way we were going to approach patient care. I cannot tell you how many times we moved those mixed areas. We are so thankful for our partners for being with us on that. I would say that it is keeping the patients separated as well. When you look at the statistics nationwide and in Oregon, we had 30% less healthcare rate of infection than anywhere else in the country. So, we took seriously our measures of keeping our employees safe and keeping our visitors safe.
Jon: I am curious about cooperating in dealing with patients that are coming in. So many of these were asymptomatic. So, how did you manage the influx or surge of patients during some of the peak times?
Kerrie: We learned quickly to create a PUI space, which is what we call it. So, it is a person under investigation where maybe you do not have a fever, but you have got some symptoms, and we are curious enough about you that we are going to put you in a PUI space, and then we are going to try to rush your test. When your test comes back, you either rule in or out of that space. We also quickly learned about anything pre-scheduled. These are pre-scheduled surgeries and pre-scheduled burst deliveries to get a COVID test done before people have their procedure, and we rush those tests through.
Jon: With the tent spaces setup and your pre-screening, in the actual outpatient setting, were there things that you set up differently? How did you alter your facilities?
Kerrie: There were so many sneeze guards. There were just so many sneeze guards and then the six-foot separation. There were waiting rooms that were making sure that people were not next to each other. In the hallways and elevators, we have got the bubbles that you stand on in an elevator that are holding people back in the lobby and not letting them go up in elevators where they will be crowded. We are making sure that people can maintain a separation when they are in any one of our facilities. Telehealth just went boom. We tried, as a nation, for so long to push Telehealth. Suddenly, Telehealth volumes are like 30% of your volume. People just adopted in remote work. People just adopted this technology overnight that we struggled so long to launch as a society.
John: Based on the lessons you have learned, what would you tell your planners, contractors, designers, and engineers that we should be focusing on in the future of healthcare?
Kerrie: There are three main things that come to my mind. … No. 1, I do not think I would ever build another med-surge side room. Even if you were going to use it for med-surge, even if you were like, “No. This is a recovering GI suite, or it is an OBS unit,” I would size it for critical care. I would have the infrastructure there behind it so you can flip it. As our population gets older, we have kind of known that the hospitals are going to become more acute, the populations are going to get older, and they are going to get sicker. You are going to have less lower acuity hospital use, and you are going to have a higher acuity population.
So, No. 1, I would size everything for critical care, for sure. Secondarily, when Ebola was starting a crisis and going on, one of our hospitals up in Washington built an Ebola unit. In that Ebola unit, the entire unit could go to negative air. Not just the rooms but the corridors, the nurse’s station, and the entire floor. I would have one of those in a hospital. If you were designing from scratch, or if you were thinking about a serious retrofit, I would try to do an entire negative unit so that you are not messing around with partitions and barriers and trying to figure out cooperation. In that way, you can say, “Okay. This is an infectious floor, and everybody on this floor is infectious, but we are not exposing other patients or worrying about how staff are traveling back and through on the floor.” Probably the third thing I would think about is in the MOBs. We were sticking hospitals. But in the MOBs, we have shared air. We do not tend to have any isolation or negative air rooms. I would put one MOB in at least one so that in a pandemic or an outbreak, you could receive a potentially infectious population and have them there until you could get them to to transition someplace more stable.
The parking lots became our friends for drive-up testing. I was thinking in the future if we can do vaccines. Is there even any reason you cannot go to a drive-through and get a flu shot or any other type of immunization? So, when you are thinking of designing from the ground up, having a parking lot that maybe even has a little hub, whether it is kind of a contractor job site trailer that has a bathroom and someplace for the staff to be, having a drive-up spot is great. We did mother and baby checks in drive-up spots so that moms did not have to come into clinics. We did pharmacotherapy checks in parking lots. I think you could do a lot in a drive-up setting where people are not even necessarily getting out of their car.
Jon: So, whether it is water, power, backup power or data, having that Wi-Fi connectivity so you can have that set up, I think those are all kind of important things that could help support that flexibility of outside space.
Kerrie: Yes. I totally agree. Because we were running on generators because you must hold the tests in a cold location until the lab can come pick them up. So, it is absolutely the emergency power and a lot of others.
Jon: Going back indoors, that flexible chassis you are talking about that could support an ICU versus just a standard surge bed, that is a bit more of a square footage, and it also has a different nursing set up as well. Because you must have the visibility in the ratio. So, everything gets a little bit bigger. That is a big investment to have that capability to convert rooms.
Kerrie: The med gases, even if they are just behind the wall, and then you put an M-cap over it, having that infrastructure there, you are right that it is a big investment. But it still is an investment that you do not make a second time, right? You can redo paint, and you can redo flooring, but if you have got the infrastructure there to support it, then you can convert it.
Jon: Thinking about other areas in the hospital that might be adaptable as well other than the critical care area, what are your thoughts on always starting with the operating areas? There are thoughts about trying to create a couple of negative pressure rooms or setups. Is that in line with some of what you all are thinking of?
Kerrie: It is. In fact, when we were surging, we were trying to figure out the machine that you use for anesthesia when somebody is in surgery and could work as a ventilator or an appendage. So, those were some of our thoughts as well. It is how do you build that flexibility into, not only just your inpatient spaces, but in your ORs, and all your other different units as well?
Jon: A lot of surge space that we helped reconfigure during the surge time were kind of pre- and post-op areas. Some emergency departments needed some flex space as well. What are your thoughts on what those areas should be looking like in the future?
Kerrie: To add to that, we also had some inpatient spaces that had been vacated that we quickly turned back online in case the surge came. We ended up using one of them at our Milwaukee hospital. We had a vacated unit that we brought back online, got all the gases up and running, and then we ended up using it for the wildfires because we had to evacuate out of the hospital. We did not have to use it for COVID, but we ended up using it for the wildfires. We are lucky to have a great architect on staff at Providence that helps us think through what our standards should be. That worked on what should the ORS be? How do we set up the EDs? How long is this COVID going to be with us, and how does it impact our future? Are we in for more pandemics as we become a more global society, and as we get more connected? Those bodies of work sort of just began. I do not know if we have clear vision, but we are super deep in conversations.
Jon: In the outpatient settings, what do you see could be some improvements there moving forward to the built environment that could benefit delivering patient care better?
Kerrie: What is interesting is that we are still so understaffed in primary care in this country that you could move a full 25% of the volumes to Telehealth, and then just keep your physicians’ roster full and bring on more patients. It is still such a need in our country. So, I do not know that you would immediately need to downsize your clinics or to change how their layouts are because of the impacts of Telehealth, but I think an interesting question is where does Telehealth happen? Is the provider in a room seeing a patient? And then in between his day, he uses that same room as Telehealth? Or does he or she work Monday, Wednesday, and Friday in the clinic, and Tuesday and Thursday from home? Do they do Telehealth at home?
We have not seen a tremendous amount of to downsize yet from the Telehealth volumes. I think in rehab, Telehealth physical therapy is super interesting. How much could you do with Zoom and with your home equipment? Would that lessen people wanting to come in? I think Telehealth behavioral health is just an area that could absolutely explode.
The episodes, “Recalibrating Medical Facilities Amid Disasters,” A Special 2-Part Report from California and Oregon,” are FREE for healthcare provider employees & AMFP members. Both parts of this episode are available now on-demand. You can watch at your convenience. If you are not an AMFP member or healthcare provider employer, you can view each episode for $30. Click here for all the episodes.