Research Journal Volume 12.01

Research Journal

2020 ― Volume 12.01

Research Journal 2020 ― Volume 12.01

Editors: Ajla Aksamija, Ph.D., LEED AP® BD+C, CDT Kalpana Kuttaiah, Associate AIA, LEED AP® BD+C Journal Design & Layout: Kalpana Kuttaiah, Associate AIA, LEED AP® BD+C

Acknowledgements: We would like to extend our appreciation to everyone who contributed to the research work and articles published within this journal.

Perkins&Will is an interdisciplinary design practice offering services in the areas of Architecture, Interior Design, Branded Environments, Planning and Strategies, and Urban Design.

Research Journal 2020 ― Volume 12.01

Research Journal

2020 ― Volume 12.01

Journal Overview The Perkin&Will Research Journal documents research relating to the architectural and design practice. Architectural design requires immense amounts of information for inspiration, creation, and construction of buildings. Considerations for sustainability, innovation, and high-performance designs lead the way of our practice where research is an integral part of the process. The themes included in this journal illustrate types of projects and inquiries undertaken at Perkins&Will and capture research questions, methodologies, and results of these inquiries.

The Perkins&Will Research Journal is a peer-reviewed research journal dedicated to documenting and presenting practice-related research associated with buildings and their environments. The unique aspect of this journal is that it conveys practice-oriented research aimed at supporting our teams.

This is the 23rd issue of the Perkins&Will Research Journal. We welcome contributions for future issues.

Research is systematic investigation into existing knowledge in order to discover or revise facts or add to knowledge about a certain topic. In architectural design, we take an existing condition and improve upon it with our design solutions. During the design process we constantly gather and evaluate information from different sources and apply it to solve our design problems, thus creating new information and knowledge.

An important part of the research process is documentation and communication. We are sharing combined efforts and findings of Perkins&Will researchers and project teams within this journal.

Perkins&Will engages in the following areas of research: nj Practice related research nj Resilience and sustainable design nj Strategies for operational efficiency nj Advanced building technology and performance nj Design process benchmarking nj Carbon and energy analysis nj Organizational behavior

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Editorial This issue of the Perkins&Will Research Journal includes four articles that focus on different research topics, including investigation of wood cladding materials, designing for school safety, analysis of sustainability and wellness certification programs, and planning strategies for healthcare facilities that account for infectious pandemic surge. This year will be remembered for a long time, since COVID-19 had a profound global impact on our health and well-being, education, work, economy, leisure, travel, and the built environment. Future research studies will be investigating long-term effects of this pandemic on our society.

Nevertheless, this issue of the Perkins&Will Research Journal reflects some of the current critical questions facing our profession. It offers insights for environmentally responsible and resilient design strategies, design methods for safe schools, well-being in commercial office buildings, and the design of healthcare facilities that are prepared for future pandemics.

“Wood Cladding for Minnesota’s Bell Museum” presents research conducted for a new natural history museum, focusing on investigation and analysis of several wool cladding materials that were considered for the building’s facades. The article reviews four woodtreating options, which were evaluated for cost, durability, sourcing, warranty, and appearance. Thermally modified wood cladding was chosen and incorporated into the final facade design, reflecting the values and cultural goals of the institution through environmentally-friendly building skin design.

“Design for School Safety: An Overview of Crime Prevention through Environmental Design” discusses design approaches for safety and security in educational buildings. The article reviews relevant literature, and presents results of a survey. The research suggests that design strategies may provide students with objective safety, as well perceived sense of safety, and concludes that more research is needed on this topic.

“Wellness Certifications Matter: A Survey of Occupants of the Perkins&Will Dallas Studio in the Pursuit of LEED, WELL, and Fitwel Certifications” analyzes different sustainability and well-being certification rating programs that were implemented during the renovation of a historic building. The research methods included pre-occupancy and post-occupancy evaluation surveys, which were administered to employees before and after the renovation.

Results indicate that significant wellness improvements were achieved.

“Planning for the Best-Case Scenario: Infectious Pandemic Surge Intensive Care Unit Program” reviews results of a literature review and interviews. This research investigated methods for planning intensive care units, which can accommodate an increase in services resulting from a pandemic. The article suggests operational strategies for ICUs that have dual functions—one during regular operations and one during an infectious pandemic surge.

Ajla Aksamija, PhD, LEED AP® BD+C, CDT Kalpana Kuttaiah, Associate AIA, LEED AP® BD+C 3

Contents Journal Overview

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Editorial

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01: Wood Cladding for Minnesota's Bell Museum Doug Bergert, AIA, LEED AP®

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Pratibha Chauhan

02: Design for School Safety: An Overview of Crime Prevention through Environmental Design

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Daniel J. Lamoreaux, PhD, NCSP Eve Edelstein, PhD, MArch, Assoc. AIA, F-AAA

03: Wellness Certifications Matter: A Survey of Occupants of the Perkins&Will Dallas Studio in the Pursuit of LEED, WELL, and Fitwel Certifications

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Garrett Ferguson, AIA, LEED AP® BD+C, WELL AP

04: Planning for the Best-Case Scenario: Infectious Pandemic Surge and the Intensive Care Unit Program

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Susan Ealer, NCARB, LEED AP ID+C ®

Peer Reviewers

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Authors

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Wood Cladding for Minnesota's Bell Museum

01 Wood Cladding for Minnesota’s Bell Museum Doug Bergert, AIA, LEED AP®, doug.bergert@perkinswill.com Pratibha Chauhan, pratibha.chauhan@perkinswill.com

Abstract Tasked by our client to identify a local wood cladding product that met their institutional and budget goals, we researched several products for a new natural history museum in Minnesota. Ultimately, the Minneapolis Perkins&Will team designed and specified an environmentally responsible building façade assembly that aligns with the client’s budget, values, and aspirations - while meeting institutional durability and maintenance requirements.

Four options were evaluated for cost, durability, source, warranty, and appearance. A single product met the client’s criteria. Situated within a broader learning landscape and urban wildlife habitat, sustainably sourced thermally modified wood siding wraps the new museum building. This solution enabled the project team to meet the project budget, while embodying the values and cultural goals of the institution through the building façade design.

This initial project-related research evolved into a much larger research topic that continues to bring together a variety of local academic and industry experts, as well as architecture firms interested in employing sustainable wood in their projects.

Keywords: resilient, local, FSC, wood, siding, thermal modification

1.0 Introduction Nearly half of the Bell Museum’s exterior is clad in eastern white pine siding (Figure 1). Typically, white pine is not considered an acceptable material for building envelope, but for this project its performance is exemplary. Clear-grained, stable, and strong—in the 19th century, white pine was in great demand for use in furniture, building structures, and, most famously, masts for sailing ships. One of the largest tree species found in North America, some measure over eight feet in diameter and two hundred feet tall.

vital to our client that the new building feature local materials. And like the learning landscape it occupies, the building needed to offer opportunities to tell Minnesota’s natural history stories (Figure 3).

In alignment with the university’s commitment to sustainability and the museum’s focus on wildlife, all the exterior glazing includes a bird-safe frit pattern.

Recalling the Iron Range mining heritage of Minnesota, much of the building is clad in panelized steel. Finally, 40 percent of the building envelope utilizes thermally modified white pine board siding. A product of responsibly managed Minnesota forests, this material aligns perfectly with the sustainability and storytelling priorities of our client. But like many journeys, we took a circuitous path to the destination.

Featuring the work of renowned diorama artist Francis Lee Jaques, the new Bell Museum is Minnesota’s natural history museum and a gateway to University of Minnesota research (Figure 2). As a site for Minnesotans and visitors to learn about the world we inhabit, it was

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Figure 1: Thermally modified white pine cladding at work in Minnesota.

Figure 2: Bell Museum site.

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Wood Cladding for Minnesota's Bell Museum

Figure 3: Bell Museum learning landscape.

2.0 Local Industry Partners

The University of Minnesota supports this evolution with the work of the Department of Forest Resources, part of the College of Food, Agricultural and Natural Resource Sciences, whom we consulted in the early stages of our product research. Later, we learned about the Natural Resources Research Institute, a non-profit applied research group, located at the University of MinnesotaDuluth. A tremendous resource for information on forest product development, the NRRI Materials and Bioeconomy research group plays an important role in the development of wood modification technologies.

Its focus on strengthening the bioeconomy of northern Minnesota aligned well with the resilience goals of the project team.

Our studio had never designed a wood-clad building.

After receiving an enthusiastic response to the proposed wood cladding design, we looked to precedents and local industry partners for help. We were impressed by the robust materiality of the Living with Lakes Research Centre at Laurentian University, designed by Perkins&Will Vancouver, completed in 2011. Our design team appreciated the weathering-to-gray exterior siding and the material’s connections to the local economy. We aspired to a similar alignment with our client’s values.

Because of sustainable management, Minnesota forestry is shifting back to lumber harvesting, after decades of focus on pulpwood for paper manufacturing.

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3.0 Cladding Literature Review and Research

intensity (temperature & time), inert atmosphere and conditioning.2

Wood treatment technologies have been available for decades. However, due to the emergence of several environmental (deforestation), economic (increase in price of available wood), and regulatory pressures (governmental regulations on use of toxins), there is a renewed interest in the commercialization of these technologies.1

Tasked by the University of Minnesota to identify a local wood cladding product that met their institutional and budget goals, we applied our understanding of modification processes to narrow down a list of four modified wood products. The results of this research were compiled and presented to our client. Durability and minimal maintenance were prioritized. Also, the client required a reasonable warranty on the material.

The findings are summarized in Figure 4.

The first scientific study in thermal modification was conducted in 1920, proving that heat decreases moisture content and the ability to swell in wood species. 2 This research was conducted at the Forest Product Research Lab in Madison, Wisconsin in the 1920s.3 In 1937, other research emerged establishing that heating wood under specific gaseous conditions leads to a substantial decrease in shrinkage, moisture, and swelling.4 This study was subsequently followed by another study in 1949, highlighting that heating wood at specific temperatures and under controlled conditions increases dimensional stability and anti-fungal properties.5

Wood cladding products reviewed 1. Eastern white cedar shakes 2. Wood acetylation 3. Charred wood 4. Thermally Modified Timber (TMT) Eastern white cedar shakes

Simultaneously, many efforts to develop and industrialize various wood processes were done in Japan, Canada, and Latvia in the 1970s and 1980s.

Despite these efforts, wood modification technologies failed to move into the mainstream.6 Europe emerged as a leader and established systematic R&D efforts leading to the implementation of industrial processes in various European nations in the 2000s. Eventually Finland, the Netherlands, and Germany achieved market leadership in the development of key modification processes available today.

nj Sourced from FSC certified forests in northern Minnesota nj Supports local economy. Made in Duluth, Minnesota nj Excellent durability, 25-year lifespan, without finishing, 50-year warranty, sealed nj Maintenance—most sealers require reapplication every 3-5 years nj Durability—excellent nj Decay resistance—very good

Current wood modification processes can be divided into three different categories: thermal, chemical, and furfurylation. These processes alter the cellular structure of wood, which is composed of cellulose, hemicellulose, and lignin polymers—all of which are hydroxyl groups that react with water molecules, leading to decay.6 The main advantages of thermal treatment is increased durability, decay resistance, dimensional stability, and UV resistance. The drawback of the process is mainly reduction in the mechanical properties of wood: bending, compression, stiffness, and shear strength.

Chemical processes use chemical substances to alter the wood structure. Thermal processes alter the wood by using a combination of different factors: treatment

nj Warranty is not available for FSC certified cedar in Minnesota nj Cost—low Wood acetylation products nj Sourced from New Zealand Radiata Pine nj Acetylation process occurs in the Netherlands nj Maintenance—minimal nj Durability—excellent

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Wood Cladding for Minnesota's Bell Museum

nj Decay resistance—excellent

Thermally Modified Timber (TMT)

nj Warranty—50-year warranty

nj Sourced from FSC certified forests in northern Minnesota

nj Cost—medium

nj Supports local economy; harvested, milled, and treated in northern Minnesota

Charred wood

nj Maintenance—minimal

nj Potentially sourced from FSC certified forests in northern Minnesota

nj Durability—excellent nj Decay resistance—excellent

nj No local char treatment facilities. Likely shipped to Texas for char nj Durability—good

nj Warranty—typically a 25-year warranty, but a 40-year warranty is available

nj Decay resistance—excellent

nj Cost—low.

nj Maintenance—Can be left unsealed, but usually sealed, reapplied every 7-10 years

As illustrated through the findings and Figure 4, eastern white cedar shakes were not available with a satisfactory warranty. The warranty for acetylated wood is very good, but it was disqualified by its overseas source and the toxicity of its chemical treatment. Short warranty and high price eliminated charred wood from consideration. The “cooked’” option, thermally modified timber, was the last product added to the evaluation set.

But, as shown in Figure 4, it meets the criteria best.

nj Historically proven service life—installations lasting 60-100 years nj Warranty—5-years nj Cost—high

White Cedar Shakes

Chemically Modified Wood

Shou-sugi-ban

Figure 4: Bell Museum wood products evaluation matrix.

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Figure 5: Material journey.

At the start of our research, we were aware of local building projects that used the other three options successfully, but most of the identified TMT precedents were in Europe. However, a local source for TMT was identified, located in Duluth, Minnesota. Using wood treatment technology developed in Finland and enhanced by NRRI research, the local source offers several thermally modified wood products, including

flooring, decking, and siding. These products are “cooked” about eighty miles from Duluth at the Superior Thermowood kiln, in Palisade, Minnesota. Supporting environmentally responsible forestry strengthens the economy of Minnesota, site of over 6 million FSC certified forest acres.7 The treatment facility, kiln, sawmill, and forests all lie within a 75-mile radius in northern Minnesota, bolstering that economy (Figure 5).

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Wood Cladding for Minnesota's Bell Museum

From the elevation view, the cladding displays a coarse surface. The design team developed this distinctive siding pattern of varying board widths and depths to provide generous surface area for enhanced drying capacity after exposure to moisture (Figure 6). The white pine boards are left rough, sawn and unfinished.

Reduced cost is one benefit of this crude surface, but for the design team the rough-sawn texture provided a window into the origin story of the building envelope.

With minimal finishing, the thermally modified boards are simply cooked, cut, and installed—the rough surface recalling the uneven bark of a white pine tree.

Figure 6: Thermally modified wood cladding detail.

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4.0 Further Study

pre-harvest modification category surveyed different ways of using wood before harvesting as a means of increasing durability. This entails strategically employing inherent strengths of as-found wood or employing processes, such as girdling, before the tree is harvested.

Post-harvest categories studied for this research included cellular and design-based methods that individually or in combination with other strategies make wood more resilient as a building material. The primary purpose of this phase was to develop a broader understanding of different factors that affect wood modification, from its cellular composition to building assembly level (Figure 7).

This project-based research evolved into a collaborative research effort between the University of Minnesota’s Architectural Research Consortium and project team, which allows academics, students, and practitioners to jointly explore a research topic benefiting both academia and the building industry.

The first phase of the expanded research project consisted of a literature review of available research materials to understand known modification processes, including pre-harvest and post-harvest methods. The

Figure 7: Classification of wood modification processes into pre- and post-harvest categories.

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Wood Cladding for Minnesota's Bell Museum

Figure 8: Self-shading design strategies.

The literature review allowed us to understand nuances of different modification processes and how these processes enhance wood’s performance as a material by altering the molecular structure of the cell wall component (Figure 8).

We used the information gathered during the literature review phase to create a decision matrix that can be used as a reference guide for selecting different modificationbased products. The matrix gives a synthesized summary of different strengths and weaknesses associated with a specific modification process, such as decay resistance, durability, color, suitable species, cost, etc., and allows users to make an informed choice based on their selection criteria (Table 1).

Table 1: Matrix comparing different products based on key criteria. Higher number = higher importance rating, example: score 7= highest importance, score 1= lowest importance.

Legend S = Same as industry benchmark - = Worse than industry benchmark + = Better than industry benchmark

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Figure 9: Building and landscape enable journeys of discovery.

5.0 Conclusion

Acknowledgments

Recent developments in forestry and wood treatment technologies offer great opportunities for healthy building projects. Promoting local economies and biodiversity, 100 percent of the wood cladding used on the Bell Museum is FSC certified. At the new Bell Museum, thermally modified white pine cladding amplifies the experience of the natural environment with a non-toxic, durable, low-maintenance cladding product (Figure 9).

These qualities are available to any building owner that wants to embody their commitment to sustainability with a beautiful, robust material. Additionally, this project generated robust knowledge sharing around the topic of wood treatments amongst academia, industry partners, and Perkins&Will.

Dave Dimond, of Perkins&Will, led the design effort for the Bell Museum.

Patrick Donahue, of the Natural Resources Research Institute, was a valuable source of information on wood modification technologies.

Jacob Mans, Assistant Professor at the University of Minnesota, provided invaluable guidance for the consortium research project.

Douglas Pierce, of Perkins&Will, championed the sustainability and resiliency strategies for the project.

References [1] Sandberg, D., Kutnar, A., and Mantanis, G., (2017).

“Wood Modification Technologies - A Review”, iForest Biogeosciences and Forestry, Vol 10, pp. 895-908.

[2] Candelier, K., Thevenon, M-F., Petrissans, A., Dumarcay, St., Gerardin, P., and Petrissans, M., (2016).

“Control of Wood Thermal Treatment and Its Effects on Decay Resistance: A Review”, Annals of Forest Science, Vol. 73, No. 3, pp. 571–583.

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[3] Hill, C., (2011). “Wood Modification: Update”, Bioresources, Vol. 6, No. 2, pp. 918-919.

[4] Stamm, A., and Hansen, L., (1937). “Minimizing Wood Shrinkage and Swelling Effect of Heating in Various Gases”, Industrial & Engineering Chemistry, Vol. 29, No. 7, pp. 831–833.

[5] Stamm, A., Burr, H., and Kline, A., (1946).

“Staybwood-A Heat Stabilized Wood”, Industrial & Engineering Chemistry, Vol. 38, pp. 630–634.

[6] Homan, W. , and Jorissen, A., (2004). “Wood Modification Developments”, Heron, Vol. 49, No 4, pp. 361-385.

[7] Forestry Stewardship Council, (2018). “FSC US Management Certified Acres by State 2018”, Retrieved on 10/2020 from https://us.fsc.org/preview.fsc-certifiedacres-by-state.a-204.pdf.

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02 Design for School Safety: An Overview of Crime Prevention through Environmental Design Daniel J. Lamoreaux, PhD, NCSP, djlamoreaux@gmail.com Eve Edelstein, PhD, MArch, Assoc. AIA, F-AAA, neuroarchitecture@gmail.com

Abstract Given the ongoing climate of fear surrounding gun violence in K-12 schools, safety and security for school facilities have come to the forefront as a top priority for architects and designers. Unfortunately, very little scientific research exists to recommend design approaches that measurably impact school violence rates. This article seeks to provide a brief overview of approaches to design for safety and security, highlights Crime Prevention through Environmental Design (CPTED) as the current forerunner among available strategies, outlines current research on CPTED, and indicates research gaps needing exploration. The authors summarize the limited number of current studies on CPTED in educational environments, highlighting the seminal findings of a recent survey that investigated the relationship between CPTED school designs and perceived safety among 900 students in three middle schools and four high schools in the American Southwest. Current research suggests that CPTED may provide students in school environments both objective safety, as well as a perceived sense of safety. Discussion also elucidates the need for consideration of students’ perceptions of school designs, as they relate to their sense of safety and overall psychological wellbeing.

The paucity of empirical studies on this topic suggests that much more research is needed.

Keywords: violence prevention, education, security, school, safety, design

1.0 Introduction Frequent reports of school victimization and violence rates increasingly propose the insertion of security measures into K-12 school environments.1 Unfortunately, research has found that such measures may be antithetical to a learner-friendly environment. Many studies have found that visible security measures such as metal detectors, locked doors, and hall monitors lead students to worry more about their safety, potential crime, and violence.2, 3, 4 Not only do visible security measures negatively impact student perceptions, but there is little evidence to indicate that they effectively reduce school crime and violence.5, 6

positive school climates are associated with enhanced perceived safety,⁹ the cultivation of design that increases perceived safety warrants greater attention in school security efforts.

In support of this assertion, this article summarizes published research on the topic of design for safety as it applies to learning environments, and highlights current promising avenues of investigation regarding Crime Prevention through Environmental Design (CPTED). The article also reviews findings from a recent photographbased survey of 900 adolescents indicating a positive relationship between students’ perceived safety and the inclusion of features of CPTED school design. The authors close with a discussion of existing literature gaps and where future research is needed.

As an alternative, designing schools that support a healthy psychosocial climate may also make them safer by reducing bullying, crime, and violence,7 thereby leading to improved academic performance.⁸ Because

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2.0 Methodology

3.2 Reducing Crime by Design

To produce this literature summary, the authors drew on a collection of empirical literature amassed from the primary author’s dissertation,10 as well as a targeted search of online databases to explore more recent research. Rather than using an extensive, systematic review process, a more targeted “scoping review” process was utilized to find the most recent research on this topic. Varying iterations of key terms, such as “CPTED,” “architecture,” “school facilities,” and “safety/ security”, were used in several major research and university databases. The main review of literature began with the primary author’s doctoral dissertation literature collection, which was then extended to include 19 additional relevant articles published during the preparation of this article. The authors identified a total of 122 articles and four books for initial review, after which thirty-six of these were determined to merit final inclusion due to their relevance to the physical environment and its impact on crime, violence, safety, or various aspects of human functioning (i.e. learning, emotion, mental health, physical health, etc.).

Many published theories have been proposed to mitigate crime and violence by virtue of the design of the built environment. Rational choice theory suggests that offenders engage in a decision-making process weighing the pros and cons of a crime, and that if the utility of what can be gained from the crime is sufficient, an attempt will be made.15 However, a large body of literature discredits this theory due to its untestable nature and its assumption that humans are self-serving, which is at odds with more broadly accepted scientific views that humans are social animals.15 Routine pattern activity posits that changes in people’s daily routines at the individual, community, and societal levels lead to changes in crime trends; further, the variable relationship between the offender, a target, and the presence/ absence of a capable guardian affects opportunities for crime occurrence.16 Crime pattern theory integrates the rational choice and routine pattern activity theories and expands them by emphasizing other factors such as socio-cultural, economic, and physical environment factors. It asserts that “how targets come to the attention of offenders influences the distribution of crime events over time, space, and among targets.” 17 Similarly, Crime Prevention through Social Development (CPSD) recognizes the complex social, economic, and cultural factors contributing to crime, thus it encourages social programs that target racial disparities, socioeconomic challenges, and family-oriented policies.18

3.0 Results 3.1 Literature Review Findings from our literature review indicate that certain spaces in school environments are consistently associated with acts of violence, victimization, or fear.11 Biag found that when thirty students were asked to take pictures of safe and unsafe spaces on their school campus, they indicated that unsafe locations were mainly outside of the traditional classroom, were undersupervised, and unknown by school personnel.12 These included “undefined” and “unowned” spaces, such as hallways, cafeterias, parking lots, and bathrooms, corroborating earlier studies.13 In addition, other research has noted related patterns, consistently finding that students associated safe spaces with the presence of supportive adults.11, 14 Thus, cultivation of ownership over all school spaces as well as supervision by, and access to, trusted adults may be critical factors to consider in school facility design. This suggests that design that affords staff an increased ability to monitor students and lend support would be beneficial.

While all of the above-mentioned theories account for the role of built settings in crime, architect Oscar Newman’s defensible space theory more explicitly explored how the physical environment can reduce the opportunity for crime.19 His original framework relied on the principles of territoriality, natural surveillance, and image/milieu to manipulate the design and layout of physical space. Empirical evidence generally supports the impact of these approaches in reducing crime, and later work has confirmed the importance of Newman’s image/milieu concept. For instance, the “broken windows” studies show increased crime and antisocial acts in spaces that are poorly maintained and in disrepair.20

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3.3 Crime Prevention through Environmental Design (CPTED) Principles

CPTED represents one approach that could allow for an increased sense of safety in students, while addressing school security and violence prevention. By utilizing subtle, covert methods “baked in” to the design and layout of school campuses, CPTED could also allow for a positive, welcoming, and supportive environment with enhanced safety, including visual and physical access to school staff. For example, the principle of natural surveillance encourages windows and openness, which promotes classroom daylighting and nature views. Also, territoriality and maintenance may be promoted by design that considers cleanliness, materials durability, and visual orderliness. The use of vegetation and stress-reducing natural elements (i.e. rocks, trees, shrubs) to mark boundaries may also foster mental restoration on campus.

Building on the ideas of defensible space, the Crime Prevention through Environmental Design (CPTED) framework provides a structured and design-specific approach that has been utilized by architects and designers for several decades. Based on the idea that the physical environment influences human choice and behavior, CPTED was first formally outlined by C. Ray Jeffery,21 who acknowledged crucial contributions from Oscar Newman and Jane Jacobs,22 who put forth ideas about elements needed for safe urban environments.

In the simplest terms, CPTED seeks to use the physical environment to discourage criminals from engaging in crime and reduce opportunities for crimes to be committed.23 Since its initial conceptualization, CPTED has undergone several phases of evolution,24 and while it has regularly changed form, it has mostly maintained its core pillars.

3.4 School Security Technologies Along with ongoing development of crime-prevention design frameworks, there has also been an increased focus on security technologies in recent years, though some technologies appear to be at odds with CPTED principles. For example, American public schools have seen a continual increase in the use of security cameras and metal detectors, 27 but these do not represent the “natural” form of surveillance espoused

by CPTED. Additionally, as previously mentioned, studies suggest that visible security measures can actually increase student fear.³ Other novel technologies, such as remote door-locking controls and alarm systems triggered by gunshot noise, take a less outwardly-visible approach and may be more conducive to maintaining a non-threatening environment; however, most new technologies are implemented with minimal-to-no scientific evidence of their efficacy in creating safer schools. 28 Furthermore, many scholars warn that a “target-hardening” approach that over-relies on security technologies can have adverse effects on students and the school environment.29 Therefore, a tempered approach using CPTED may more effectively strike a balance between safety and student wellbeing, though research on this matter is nascent.

While the literature is mixed in determining which concepts are considered central to CPTED,25 the following four are nearly always included and are often referenced in school design literature26: nj Natural Surveillance: Supports the idea of “see and be seen”; advocates the use of windows and open layouts, among other strategies, to optimize sight lines and facilitate the continual monitoring of important spaces. nj Access Control: Refers to selecting who is allowed to enter and exit a space, which primarily involves minimizing the number of entry/exit points and channeling visitors to secure locations where they can be monitored and vetted. nj Territoriality: Involves delineating clear and discrete spaces by providing visual cues in the built environment, such as landscaping elements to mark borders, sidewalks to designate where visitors can walk, and signage that communicates behavior expectations (i.e. “drug free campus” signs). nj Maintenance: supports the concept of territoriality, as dirty, neglected, and vandalized spaces send a message that no one feels a sense of ownership or concern about such spaces.

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3.5 School-Based Implementation of CPTED

photographs that depicted similar school areas with and without design elements representing the primary CPTED principles: (1) Natural Surveillance, (2) Access Control, and (3) Territoriality/Maintenance (See Tables 1, 2, and 3 below). Students completed the survey while at their campuses using Qualtrics online survey software and school computers.

General research on the implementation of CPTED strategies shows efficacy in residential and commercial settings.24 However, research on CPTED in educational settings is limited to only a handful of studies, and it is unclear how the use of CPTED impacts student sense of safety and school climate. An early school-based application was demonstrated by Wallis and Ford, in which the implementation of CPTED informed design alterations at four high schools and resulted in increased surveillance and reduced crime victimization. 30 Surprisingly, a positive impact on student perceived safety was not evident. Recently, Vagi et al. found that secondary school facilities with closer adherence to CPTED principles tended to have lower reported rates of violence and aggression.31 Their results also indicated that schools with greater use of CPTED design elements had lower rates of absenteeism stemming from fear for safety. Additionally, Shariati and Guerette indicated that students living in residential university dormitories with higher utilization of CPTED strategies perceived greater safety than those in dormitories with low use of CPTED elements.32 While each of these studies indicates promise, school-based CPTED research is scarce and much more is needed.

Lamoreaux and Sulkowski’s survey results indicated that students had a significantly greater preference for CPTED versus non-CPTED school designs, both in terms of perceived physical safety (p <.01, d = .84, large effect size) and psychological comfort (p <.01, d = .70, large effect size).33 Lamoreaux and Sulkowski’s analyses indicated that age, ethnicity, and gender did not demonstrate meaningful impacts on CPTED preferences. Similarly, a student’s prior exposure to violence did not correlate with a meaningful difference in the overall preference for CPTED designs, neither for perceived safety (p > .05) or psychological comfort (p > .05). Students with a history of delinquent behavior demonstrated a statistically significant preference for non-CPTED design photos for perceived physical safety (p = .05, d = .25) and psychological comfort (p < .05, d = .26), however the effect sizes (d) for both of these results are considered small and of marginal practical significance. Lastly, self-reported academic achievement did not show a statistically significant correlation (r) with students’ CPTED preferences regarding perceived safety (r = .02, p = .51) or psychological comfort (r = .03, p = .46).

In short, most of the individual differences among survey participants did not exert an impact on the collective preference for the depicted CPTED design strategies.

3.6 Student Perceptions of CPTED Lamoreaux and Sulkowski investigated whether schools designed around CPTED principles are perceived as being safer and more psychologically comfortable when compared to schools that do not adhere to CPTED.33 The study recruited 900 middle and high school students ranging in age from 11 to 19 years and of diverse gender, cultural, and racial/ethnic backgrounds in southern Arizona. Forty-four percent of participants were male, 54 percent were female, 0.7 percent indicated “Other,” and 1.2 percent did not indicate their sex. Student preferences were gathered via a photograph-based survey using images gathered via Google image searches, digital photographs donated by Perkins&Will design firm, and photographs taken of local schools in the region where the study was carried out. A group of graduate-level psychology students and their instructors assisted in narrowing an initial batch of 72 images down to 24 final images. The survey presented pairs of

Tables 1, 2, and 3 present the images used in the electronic survey and indicate what percentage of students preferred each CPTED school image. While student preferences favored CPTED designs overall, analysis of preference trends within each of the three CPTED principles indicates notable differences.

Lamoreaux and Sulkowski’s survey also used open-ended questions that asked students to write about specific design elements that were depicted in the survey. This qualitative data was used to expand on and elucidate the quantitative data regarding student preferences.

In some cases, there were conflicting response trends relating to preference for transparency and openness, as well as fencing and gating. These will be detailed below.

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Table 1 reveals that a solid majority of the student participants favored the Natural Surveillance images for both perceived safety as well as psychological comfort.

The preference for CPTED was slightly stronger for all four image pairs as it applied to students’ sense of psychological comfort versus physical safety. A primary response pattern among the survey’s open-ended text responses suggested that a large number of students perceived windows and openness as conducive to safety; for example, one student stated, “The ones with the windows were safer to me because I could see if anyone is coming by looking through the windows.” Interestingly, this comment, and many others like it, accurately described the premise behind natural surveillance, which is to allow users to passively monitor common spaces for unsanctioned behaviors. Students also tended to use fear-based descriptors such as “trapped” to describe windowless, enclosed spaces.

In observing the preference percentage rates in Table 2, it is apparent that Access Control may produce less perceived safety and comfort than the other CPTED principles explored by Lamoreaux and Sulkowski’s survey.

Only two of the four Access Control image pairs were favored by a majority of students for physical safety, and none of the pairs were favored for psychological comfort. One trend in the qualitative response patterns that discussed images of fences and gates provides a possible explanation for this. Many students described gates and fences as restrictive of movement, some alluding to hypothetical scenarios when they would want rapid egress. One student’s comment on the survey images embodied the collective viewpoint in this way: “I really felt more comfortable with the pictures that didn't show gates. It gives off a feeling that you are trapped, and you can't leave.” This sentiment aligns with Fisher and Nassar’s35 finding regarding elevated fear in environments with blocked escapes. Nevertheless, the percentages in Table 2 seem to indicate that at least some students favor the depicted access control strategies, and future research will need to determine the factors responsible for these opposing viewpoints.

Conversely, a smaller subset of students described a sense of fear and vulnerability associated with windows and openness. These students tended to prefer less window transparency and more fencing in order to feel safe. For instance, many responses reflected this student’s fear: “Some specific things that I saw that made me uncomfortable is windows because they could see you and kill you…”

Overall, the results outlined in Table 3 indicate that three out of four of the depicted Territoriality and Maintenance design strategies foster greater sense of safety and comfort than non-CPTED designs. More specifically, it would appear that students indicate a benefit to wellmanicured outdoor landscaping, a front office approach/ entry with clear visual cues and legibility, and “territorial” signage stating behavior restrictions on school grounds.

However, it was only a slight majority that preferred the drug free school signage for psychological comfort (51 percent for CPTED versus 49 percent for non-CPTED), and the preference for the same image regarding perceived safety was also modest (60 percent for CPTED versus 40 percent for non-CPTED). The first image pair depicting neat versus inadequate grounds maintenance demonstrated the most overwhelming CPTED preference out of all twelve image pairs. Indeed, the open-ended text responses from students regarding Territoriality/Maintenance issues made frequent mention of a preference for well-maintained grounds. One out of many comments in this response trend stated, “I saw that when the school was more well kept and clean it gave me a sense that it was safer as well.” Notably, a slight majority of students preferred the non-CPTED image that

The above-mentioned preference for enclosed, restricted space appears to contradict research findings that fear is greater in enclosed spaces34 and, more specifically, in spaces having low prospect (i.e. low visibility), high opportunity for concealment (of perpetrators), and blocked escape.35 One possible explanation for this contradiction in student preferences for design transparency was exposed by Lee and Ha.36 They explored the effect of windows/visibility on Korean students’ fear of crime in interior school environments, and their results suggested that either too much or too little visibility led to decreased sense of safety. However, this is the only study of its kind, and further investigation is needed to clarify if this phenomenon generalizes to student populations in other communities and cultures. Thus, future research will need to clarify why some students’ explicit preferences are for enclosure; it is possible that the current media focus on school-based violence fuels student fear and thereby alters their perceptions of potential threat in the physical environment.

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Table 1: PSDM Natural Surveillance survey items and percentage of response preference (N = 900).

CPTED PRINCIPLE DEPICTED

IMAGES USED IN SURVEY NON-CPTED

CPTED

Natural Surveillance

Windowless classroom

78%

67%

74%

63%

59%

57%

77%

67%

Observable common spaces

Natural Surveillance

Impeded front desk view of main entry doors

Front desk view of main entry doors

Natural Surveillance

Hall with no exterior views

PERCENT THAT PREFERRED CPTED FOR PHYSICAL SAFETY

Windowled classroom

Natural Surveillance

Minimal Observation of common spaces

PERCENT THAT PREFERRED CPTED FOR PSYCHOLOGICAL COMFORT

Hall with exterior views

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Table 2: PSDM Access Control survey items and percentage of response preference (N = 900).

CPTED PRINCIPLE DEPICTED

IMAGES USED IN SURVEY NON-CPTED

CPTED

Access Control

No perimeter fence around campus

No gated parking

47%

57%

30%

41%

32%

42%

54%

65%

Gated parking

Access Control

Fence around basketball court

Access Control

No fence around bike racks

PERCENT THAT PREFERRED CPTED FOR PHYSICAL SAFETY

Perimeter fence around campus

Access Control

No fence around basketball court

PERCENT THAT PREFERRED CPTED FOR PSYCHOLOGICAL COMFORT

Fence around bike racks

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Table 3: . PSDM Territoriality/Maintenance survey items and percentage of response preference (N = 900).

CPTED PRINCIPLE DEPICTED

IMAGES USED IN SURVEY NON-CPTED

CPTED

Territoriality/ maintenance

Windowless classroom

85%

83%

43%

48%

73%

67%

51%

60%

Observable common spaces

Territoriality/ maintenance

Impeded front desk view of main entry doors

Front desk view of main entry doors

Territoriality/ maintenance

Hall with no exterior views

PERCENT THAT PREFERRED CPTED FOR PHYSICAL SAFETY

Windowled classroom

Territoriality/ maintenance

Minimal Observation of common spaces

PERCENT THAT PREFERRED CPTED FOR PSYCHOLOGICAL COMFORT

Hall with exterior views

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lacked a designated pedestrian walkway, both in terms of perceived physical safety and psychological comfort.

This could be due to the lack of any true association with sidewalks and perceived safety or psychological comfort, or it could be due to a flaw in the selected images, such that they may not correlate sufficiently to the concept of Territoriality, even at the subconscious level among survey respondents.

Also, critics citing the limitations of CPTED point out that some iterations of its framework, particularly in the early years of its application, have been reductive and overly simplistic in suggesting physical/architectural parameters that can be manipulated in order to reduce criminal behaviors. 23 Others have suggested that CPTED approaches are deterministic, arguing that it overestimates the influence of the built environment.24 As a result, scholars have recently suggested that a “third generation CPTED” framework is needed that includes a more holistic and ecological perspective.23 Proponents suggest that CPTED be folded into a broader public health or “community liveability” perspective that accounts for increasing knowledge in sustainability and “green technology,” as well as advances in cognitive, behavioral, neurological, and environmental sciences.

4.0 Conclusions and Future Directions In reviewing the limited body of current publications on CPTED use in schools and original studies, results indicate substantial benefits from using a CPTED framework to inform design. For instance, the inclusion of CPTED principles in design may be an effective approach to engender feelings of both safety and psychological wellbeing among a majority of students.33 In addition, findings reviewed here strengthen the case that students’ sense of safety and their academic achievement may be improved as school buildings take a softer approach to safe school design. 31 In contrast, a fortress-like approach to design may neither improve safety nor the perception of safety.

4.2 Future Research Questions Lamoreaux and Sulkowski observed a dichotomy in student preferences for open versus enclosed environments that could be more accurately tested in on-site studies to determine the specific design impact of windows.33 Of interest are studies to clarify the effect of transparency and visibility on perceived safety, given current trends in architectural design that favor increased transparency, windows, and visual permeability in school buildings. Specifically, investigation is needed to understand if transparency’s impact on perceived safety is a function of quality or quantity (how much and where is transparency afforded in a given school design).

Additionally, investigations should explore whether the impact of transparency is mitigated by individual student characteristics (i.e. demographic traits or cultural experiences). Research is also needed to investigate design solutions that both permit transparency and, at the same time, provide places for visual refuge and protection from perpetrators.

Compared with other crime prevention models, CPTED has advantages in that it provides a structured and design-specific approach based on multidisciplinary perspectives from sociology, psychology, criminology, and other fields. Second generation versions of the CPTED framework have expanded to include emphases on social cohesion, community connectivity, and community culture. The inclusion of social factors that play a critical role in neighborhood safety may provide another advantage of this approach.24 Finally, empirical research indicates a positive effect of using CPTED in residential and commercial settings. However, current literature surrounding CPTED in school design is scant, thus continued studies are warranted.

Future studies exploring the impact of CPTED school designs on student perceptions also need to ask if there are personality factors such as a predisposition to anxiety or introversion that contribute to the differing preferences observed by Lamoreaux and Sulkowski.24 In addition, studies on the impact of specific designs of fencing and gates are of interest to determine if perimeter fencing alone has a measurable impact on perceived safety, and if different types of fencing (chain link, bars) have different

4.1 Possible Limitations of CPTED A CPTED approach presents with a few considerable limitations. First, as research on the use of CPTED specifically in K-12 schools is highly limited, current practices that use security design strategies are not based upon a repeated or rigorous evidence base.

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effects on perceived safety. We also propose that studies should evaluate how specific design manifestations of each CPTED principle (i.e. natural surveillance, access control, territoriality, etc.) might support perceived safety and mental wellbeing in schools.

[3] Perumean-Chaney, S., and Sutton, L., (2013). “Students and Perceived School Safety: The Impact of School Security measures”, American Journal of Criminal Justice, Vol. 38, No. 4, pp. 570-588.

[4] Schreck, C., and Miller, J., (2003). “Sources of Fear of Crime at School: What is the Relative Contribution of Disorder, Individual Characteristics, and School Cecurity?”, Journal of School Violence, Vol. 2, No. 4, pp. 57-79.

Furthermore, a more nuanced understanding of the impact of design will result from continued analysis of the other CPTED principles, beyond the four analyzed in this paper. Analysis of the specific qualities and context of design features must consider the social, economic and local conditions. Importantly, the interactions between design, individual perceptions, and the school's culture and pedagogical styles will help to reveal those design elements that are most likely to have the greatest impact on safety and student wellbeing.

[5] National Association of School Psychologists, (2013).

“Research on School Security: The Impact of Security Measures on Students”, NASP, Bethesda, MD, Retrieved on 11/2020 from http://www.audioenhancement.com/wpcontent/uploads/2014/06/school-security-by-NASP.pdf.

[6] Phaneuf, S.., (2009). Security in Schools: Its Effect on Students, El Paso: LFB Scholarly Publishing LLC.

Other CPTED research will need to focus on teachers’ (not just students’) perceived safety and comfort in CPTEDbased schools, and whether CPTED objectively reduces crime and violence rates in educational settings. Finally, the potential influence of built features on the school social environment should be investigated. For instance, the assertion that transparency enhances school connectedness demands empirical investigation; this research topic has not yet been adequately addressed, but is of great importance. As future studies explore the gaps highlighted here, thought leaders will be able to work towards a refined iteration of the CPTED framework, one that more effectively reduces violence while fomenting a stronger sense of psychological and physical safety.

[7] Wang, M., and Degol, J., (2016). “School Climate: A review of the Construct, Measurement, and Impact on Student Outcomes”, Educational Psychology Review, Vol. 28, No, 2, 315-352.

[8] Milam, A., Furr-Holden, C., and Leaf, P., (2010).

“Perceived School and Neighborhood Safety, Neighborhood Violence and Academic Achievement in Urban School Children”, The Urban Review, Vol. 42, No. 5, pp. 458-467.

[9] Kitsantas, A., Ware, H., and Martinez-Arias, R., (2004). “Students’ Perceptions of School Safety: Effects

by Community, School Environment, and Substance Use Variables”, The Journal of Early Adolescence, Vol. 24, No. 4, pp. 412-430.

[10] Lamoreaux, D., (2017). “Student Preferences for Safe and Psychologically Comfortable School Facilities”, Doctoral Dissertation, University of Arizona, Proquest Dissertations Publishing.

References [1] Musu, L., Zhang, A., Wang, K., Zhang, J., and Oudekerk, B., (2019). “Indicators of School Crime and Safety: 2018 (NCES 2019-047/NCJ 252571)”, National Center for Education Statistics, U.S. Department of Education, and Bureau of Justice Statistics, Office of Justice Programs, U.S. Department of Justice. Washington, DC.

[11] Astor, R., Benbenishty, R., Marachi, R., and Meyer, H., (2006). “The Social Context of Schools: Monitoring and Mapping Student Victimization in Schools”, in Handbook of School Violence and School Safety: From Research to Practice, Jimerson, S., and Furlong, M., eds., Mahwah, NJ: Lawrence Erlbaum Associates Publishers, pp. 221-233.

[2] Mowen, T., and Freng, A., (2019). “Is More Necessarily Better? School Security and Perceptions of Safety among Students and Parents in the United States”, American Journal of Criminal Justice, Vol. 44, No. 3, pp. 376-394.

[12] Biag, M., (2014). “Perceived School Safety: Visual Narratives from the Middle Grades”, Journal of School Violence, Vol. 13, No. 2, pp. 165-187.

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[13] Astor, R., Meyer, H., and Behre, W., (1999). “Unowned Places and Times: Maps and Interviews About Violence in High Schools”, American Educational Research Journal, Vol. 36, No. 1, pp. 3–42.

Design (CPTED)”, Journal of Planning Literature, Vol. 30, pp. 393-412.

[25] Gibson, V., and Johnson, D., (2016). “CPTED, But Not as We Know It: Investigating the Conflict of Frameworks and Terminology in Crime Prevention through Environmental Design”, Security Journal, Vol. 29, No. 2, pp. 256-275.

[14] Langhout, R., and Annear, L., (2011). “Safe and Unsafe School Spaces: Comparing Elementary School Student Perceptions to Common Ecological Interventions and Operationalizations”, Journal of Community & Applied Social Psychology, Vol. 21, No. 1, pp. 71-86.

[26] Schneider, T., (2010). “CPTED 101: Crime Prevention through Environmental Design - The Fundamentals for Schools”, National Clearinghouse for Educational Facilities, Retrieved on 11/2020 from http://www.ncef. org/pubs/cpted101.pdf.

[15] Loughran, T., Paternoster, R., Chalfin, A., and Wilson, T., (2016). “Can Rational Choice Be Considered a General Theory of Crime? Evidence from Individual-Level Panel Data”, Criminology, Vol. 54, No. 1, pp. 86-112.

[27] Robers, S., Zhang, A., Morgan, R., and Musu-Gillette, L., (2015). “Indicators of School Crime and Safety: 2014”, National Center for Education Statistics, U.S. Department of Education, and Bureau of Justice Statistics, Office of Justice Programs, U.S. Department of Justice, Washington, DC.

[16] de Melo, S., Pereira, D., Andresen, M., and Matias, L., (2018). “Spatial/Temporal Variations of Crime: A Routine Activity Theory Perspective”, International Journal of Offender Therapy and Comparative Criminology, Vol. 62, No. 7, pp. 1967-1991.

[28] King, S., and Bracy, N., (2019). “School Security in the Post-Columbine Era: Trends, Consequences, and Future Directions”, Journal of Contemporary Criminal Justice, Vol. 35, No. 3, pp. 274-295.

[17] Brantingham, P., and Brantingham, P., (1993).

“Environment, Routine, and Situation: Toward a Pattern Theory of Crime”, in Routine Activity and Rational Choice.

Advances in Criminological Theory, Vol. 5, Clarke, R., and Felson, M., eds., New Brunswick, NJ: Transaction Publications, pp. 259-294.

[29] Warnick, B., and Kapa, R., (2019). “Protecting Students from Gun Violence: Does ‘Target Hardening’ Do More Harm Than Good?”, Education Next, Vol. 19, No. 2, pp. 22-30.

[18] Olajide, S., Lizam, M., and Adewole, A., (2015).

“Towards a Crime-Free Housing: CPTED versus CPSD”, Journal of Environment and Earth Science, Vol. 5, No. 18, pp. 53-63.

[30] Wallis, A., and Ford, D., (1980). “Crime Prevention through Environmental Design: The School Demonstration in Broward County, Florida: Executive summary”, US Department of Justice, National Institute of Justice.

[19] Newman, O., (1972). Defensible Space: Crime Prevention through Urban Design, New York, NY: Macmillan.

[31] Vagi, K., Stevens, M., Simon, T., Basile, K., Carter, S. P., and Carter, S. L., (2018). “Crime Prevention Through Environmental Design (CPTED): Characteristics Associated with Violence and Safety in Middle Schools”, Journal of School Health, Vol. 88, No. 4, pp. 296-305.

[20] Reynald, D., (2015). “Environmental Design and Crime Events”, Journal of Contemporary Criminal Justice, Vol. 31, No. 1, pp. 71-89.

[21] Jeffery, C., (1971). Crime Prevention through Environmental Design, Beverly Hills, CA: Sage.

[32] Shariati, A., and Guerette, R., (2019). “Resident Students’ Perception of Safety in On-Campus Residential Facilities: Does Crime Prevention through Environmental Design (CPTED) Make a Difference?”, Journal of School Violence, Vol. 18, No. 4, pp. 570-584.

[22] Jacobs, J., (1961). The Death and Life of Great American Cities, London, UK: Jonathan Cope.

[23] Mihinjac, M., and Saville, G., (2019). “ThirdGeneration Crime Prevention through Environmental Design (CPTED)”, Social Sciences, Vol. 8, No. 6, pp. 182.

[33] Lamoreaux, D., and Sulkowski, M., (2020). “Crime Prevention through Environmental Design (CPTED) in Schools: Students’ Perceptions of Safety and Psychological Comfort”, Psychology in the Schools, article in press, https://doi.org/10.1002/pits.22459.

[24] Cozens, P., and Love, T., (2015). “A Review and Current Status of Crime Prevention through Environmental

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[34] Stamps, A., (2005). “Enclosure and Safety in Urbanscapes”, Environment and Behavior, Vol. 37, No. 1, pp. 102-133.

[35] Fisher, B., and Nasar, J., (1995). “Fear Spots in Relation to Microlevel Physical Cues: Exploring the Overlooked”, Journal of Research in Crime and Delinquency, Vol. 32, No. 2, pp. 214-239.

[36] Lee, S., and Ha, M., (2016). “The Effects of Visibility on Fear of Crime in Schools’ Interior Environments”, Journal of Asian Architecture and Building Engineering, Vol. 15, No. 3, pp. 527-534.

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03 Wellness Certifications Matter: A Survey of Occupants of the Perkins&Will Dallas Studio in the Pursuit of LEED, WELL, and Fitwel Certifications Garrett Ferguson, AIA, LEED AP® BD+C, WELL AP, garrett.ferguson@perkinswill.com

Abstract Do wellness certifications make the differences that they claim? Implementing design strategies that only focus on a singular certification, or without factoring sustainability metrics inclusive of occupant wellbeing and comfort, can result in suboptimal and regressive design qualities, and compromise several decades of diligent, high-performing work. Meanwhile, combining multiple rating systems can yield to wholistic sustainable results, ones with a raised sense of wellness, benefiting both the property owners and the occupants. The Dallas studio of Perkins&Will pursued LEED, WELL, and Fitwel certifications in the renovation of a historic building as their new office. Significant wellness impacts were observed in comparisons of the digitally administered pre-occupancy and post-occupancy evaluation surveys. As nearly all the compared metrics indicated significant positive correlation in occupant wellness, such results assert the importance of implementing these rating systems to both inform and validate design decisions.

Keywords: human behavior, built environment, LEED certification, WELL certification, Fitwel certification

1.0 Introduction The Dallas studio of Perkins&Will recently relocated to a new space—The Old Dallas High School, which was built in 1907 and served as the original Dallas High School. The blighted building was in a state of vacancy and neglect before undergoing repurposed multi-use renovation by developer Matthews Southwest with the help of design firm Merriman Anderson Architects.

The location was preferable for several reasons, but particularly due to the site’s immediate proximity and access to the Dallas Area Rapid Transit (DART) rail lines and the numerous urban core amenities. Pedestrian accessibility to multiple facilities and services were not offered at the previous location of the Perkins&Will Dallas office, a space certified under LEED v2.0 ID+C: Corporate Interiors at the Gold level.

In addition to the LEED certification, which is already the firmwide sustainability metric requirement, the office leadership elected to additionally pursue WELL and Fitwel rating systems. This was done to understand these novel rating systems and to implement their strategies into the renovation design. After significant exploration, the decision was made to pursue LEED v2009 ID+C: Corporate Interiors at the Platinum level, WELL v1 for New and Existing Interiors at the Gold level, and Fitwel v1 for three stars. Each rating system has unique goals— some of which overlap and some of which appear to contradict each other.

The WELL Building Rating System (WELL) claims its purpose is to “explore how design, operations and

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behaviors within the places where we live, work, learn and play can be optimized to advance human health and well-being.” 1 Fitwel’s goal is to “enhance buildings by addressing a broad range of health behaviors and risks.”² In an attempt to track and recognize human health effects, digital surveys were administered. Such frameworks have only recently been introduced to the industry to emphasize specific aspects of sustainability, such as wellness, resilience, net positive design, and other performance aspects.3

a scale consisting of Very Satisfied, Satisfied, Somewhat Satisfied, Neutral, Somewhat Dissatisfied, Dissatisfied, and Very Dissatisfied. Such questions provide a range of satisfaction or dissatisfaction levels. Some environmental factors that were rated were: Temperature/Thermal Comfort, Lighting Comfort/Quality, Building Cleanliness, Air Quality, Air Speed, and Humidity. The same scale was applied to more questions about acoustics, natural daylighting, and exterior views. Some other questions were structured differently, such as ranking likability and use of current vending options on a scale from 1 to 5.

It is understood that some impacts were the result of moving locations and were not a result of implementing certifications. For instance, the surveys show the number of public transit riders increased five times after initially moving to the new office. While the number does reflect a significant change, that increase is due more so to building location than wellness certification; however, those factors were specifically taken into account when selecting the Old Dallas High School for the new office.

2.0 Methodology An anonymous pre-occupancy digital survey was administered to employees 16 months before the new space was completed. The survey was created with Google Forms, a free tool for data gathering. The intent was to gather a comparable baseline of a LEED certified space, which would provide similar results to one that pursued LEED certification, in addition to implementing both WELL and Fitwel certifications. Specifically, the effects sought out were impacts or even perceived impacts on building occupants compared to a typical workplace setting. The survey primarily focused on thermal comfort, but also explored questions about office culture, wellness, I.T. implementation, parking needs, and other related topics. In order to incentivize participation, gift cards were randomly given out to a small percentage of participants. The survey and gift card entries were intentionally kept separate to keep anonymity. The first survey had 154 responses, which was over half of the office’s population at the time.

3.0 Occupant Well-Being 3.1 Personal Thermal Comfort WELL has many strategies that address thermal comfort, in addition to those noted under the LEED rating system, including multiple parameters and set points that determine what is comfortable for building occupants.

Curiously, Fitwel only directly addresses personal comfort when it incentives operable shading for occupants. A total of 61.9 percent of employees stated that they are satisfied or ambivalent with the overall temperature and thermal comfort of the space—a number that seems to be far below where it should be. Despite demonstrating compliance to ASHRAE 55 for both 2007 and 2013 for LEED and WELL, employee thermal comfort responses are noticeably contradictory.

Roughly 18 months after occupancy, a nearly identical survey was administered to the office, with 163 responses recorded. At the time of the 2nd survey, the project was still actively pursuing all three certifications, but every effort was made to implement all required and pursued strategies. Comparisons were made between the first survey (pre-occupancy survey) and the second survey (post-occupancy survey), using the first survey as the baseline.

Overall, the results of the new office showed a slight improvement than the old office; however, 56 percent of women in the new office noted that they were too cold. An easy observation of the space yields blankets, heated blankets, and other means to keep female employees warm. Such a significant portion of dissatisfied employees calls into question the methods of determining thermal comfort and whether they should be reevaluated. Discussions of the metrics

Some questions were asked with a simple ‘Yes’ or ‘No’ response, such as “Do you consider your workspace to be well lit?” or “Can you see out of a window from your desk when seated?” Other questions asked participants to rate their satisfaction with an environmental factor on

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based on suit-clad businessmen have been heard for some time, but only recently have those questions asked if such metrics are ultimately sexist and out of date. Additionally, at least one recent study shows that women in warmer environments are more productive.4 Thus, these industry standards should be adjusted to be inclusive for all employees.

Poor air quality was the 4th most common reason for employee dissatisfaction, with 17.5 percent of the office population noting the complaint. While not noted significantly in survey results, conversations around the office highlight the amount of dust in the space. Despite a well-documented Construction IAQ Plan that was implemented to mitigate construction pollution, dust continues to collect on countertops and other surfaces years later, which is believed to be a key reason for the complaints. The source of the dust remains unknown.

3.2 Indoor Air Quality Having a high-quality indoor environment is one of the biggest promises of both LEED and WELL certifications.

The office was designed to be and remains compliant with multiple strategies regarding indoor air quality, such as low-emitting materials, significant material ingredient vetting, increased filtration, and others.

Fitwel incentivizes creating an Indoor Air Quality (IAQ) Policy that includes low-emitting materials, tobacco, filtration, plant maintenance, garbage disposal, and the elimination of potential pollutants. The resulting culmination of all strategies yielded an 81 percent satisfaction rate regarding the overall IAQ. It is common knowledge within the LEED rating system that a thermal comfort survey result showing anything above a 20 percent dissatisfaction rate requires a corrective action plan. For two rating systems where IAQ is highly scrutinized, the satisfaction rate is surprisingly low, nearly requiring corrective action.

3.3 Physical Activity One of the primary objectives of Fitwel certification— increased physical activity—has not gone unnoticed in the new office, as seen in Figure 1. Responses from the previous office demonstrated clear room for improvement, with only 25 percent of responses believing that the office promoted physical activity. New survey responses demonstrate a significant change in office experiences, with 71 percent of responses now in agreement. This change in perception is noteworthy, nearly tripling the number of employees that support the belief.

Sit-stand desks were sporadic in the former office, provided only to those with required doctor’s notes or self-provided by employees. The new office has

Figure 1: Employee perceptions of their work environment impacts.

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3.4 Lighting Quality

provided sit-stand desks to 100 percent of employees.

The majority of these are motorized desks, but design constraints required occasional standing height desks with high seated chairs. Both solutions provide an opportunity to stand or sit as desired, but occupants do not necessarily agree. Despite providing sit-stand choices to all employees, 4 percent responded that they do not have a sit-stand desk at all. When asked individually, those at fixed height desks noted that, while the desks met the requirements, the lack of adjustability was noticeable. Someone too tall or short, for instance, was not able to use the high tabletop while standing without causing strain to their wrist or arms.

The introduction of new lighting metrics was initially confusing to the design team, but design requirements were eventually achieved. Notably, as a result of the new parameters from WELL, employees are happier than ever about the lighting in the office. Overall satisfaction increased from 44.8 percent to 71.8 percent. Particularly of note is that the count of those who responded as very satisfied increased from 2 to 37 answers, an improvement factor of 18.

The previous office had typical fluorescent fixtures encased in lay-in ceilings throughout most of the office space. The current office has high Color Rendering Index (CRI) LED lighting for the entire office. Each area adjacent to windows is part of a daylighting responsive system, which saves energy and can dim lights variably according to the amount of daylight introduced into the space. Additional collaboration was needed to fine tune the controls, but office management is satisfied with the results. Ultimately, high quality lighting is available throughout the space, as seen in Figure 3.

Overall, 92 percent of people said they liked their sitstand desk, as illustrated in Figure 2. The most common comment on how the moveable desks had improved personal health was that occupants had less back pain and stiffness. The second most common response was that employees had more energy and felt less tired.

Both responses are in line with the primary benefits associated with standing and the variability of sit-stand desks. Other responses included burning more calories, excitement over personal control, and increased collaboration. Interestingly, despite the overwhelming number of people saying they liked the desks, 5 percent of responses do not believe that this adaptation has improved their health.

When asked what design consideration was the most important of seven strategies, office employees ranked natural daylighting as the single most important factor.

Conversely, artificial lighting quality was overwhelmingly ranked as the least important design consideration of all the strategies.

3.5 Acoustics Despite significant efforts to comply with WELL requirements, testing has confirmed that some acoustic criteria were not yet met at the time of occupancy.

Corrective action has been planned and implemented to continue certification. Unsurprisingly, the number one complaint in the office relates to acoustics, particularly in open office settings. This is, unfortunately, in line with office design trends where acoustics are also the most common comment of disapproval.â ľ A dissatisfaction rate of 40 percent in regards to acoustics should not be taken as a criticism against WELL certification, as compliance with WELL acoustic criteria was not met at the time of the post-occupancy evaluation. Of all the reasons occupants expressed dissatisfaction in the quality of the office, 52.6 percent cited poor acoustic quality as the primary reason.

Figure 2: Responses to the sit-stand desks were overwhelmingly clear, but still provided good feedback.

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Figure 3: Collaborative spaces are scattered throughout the office to provide various types of workspaces to employees, all of which have highquality lighting.

Figure 4: The central space of the office is multiuse, but an inability to provide acoustic treatments can make it hard to hear.

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Explanations for the acoustic noncompliance lie in the history of the space. While the historic nature of the building is celebrated and inherently sustainable, constraints necessitating visual restoration created multiple challenges. Original plaster ceilings were required to be exposed after being restored under the direction of Merriman Anderson and Balfour Beatty.

While some acoustic panels were able to be added in unnoticeable areas, as shown in Figure 4, most ceilings are hard surfaces. Per requirements from the historic commission, suspended ceilings were not able to be introduced. While they would have muffled mechanical noise, they would have covered historic ceilings.

that the WELL v1 Building Rating System currently does not address acoustics in historic buildings, but they have approved the pursuit of an Alternative Adherence Path.

3.6 Nourishment and Water Prior to the office move, typical vending machines were provided by a third-party vendor. Common options included chips, candy, sodas, nuts, and other non-perishable items. The new office took great effort to change the vending to one that provided healthy options and complied with both WELL and Fitwel requirements, as seen in Figure 5. Provided options now include premade salads and sandwiches, cheese sticks, hummus, chips, trail mix, fruit, jerky, and a small amount of candy. Using both criteria from WELL and Fitwel simultaneously made food selection difficult, as each rating system has a unique approach to nourishment.

Because of the ceiling requirements, all new mechanical equipment in the space had to be exposed. Without a buffer to lessen mechanical vibrations and air movement, all noise from the HVAC is directly over occupant workspaces. The project team noted WELL acoustic criteria in advance and worked to specify quiet equipment, but were unsuccessful in implementing all necessary strategies. A white noise system was installed, but it is not currently active since it cannot be heard over the noise from the fan power boxes. It should be noted

While criticisms remain on the vending requirements and challenges, a noted 68 percent improvement was demonstrated from the pre-occupancy survey to the post-occupancy survey. The most common critique

Figure 5: : Fresh vending options are provided to employees, with everything from typical vending choices to refrigerated and low sugar selections.

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is that while the requirements of both rating systems have been met, neither system has any commentary on artificially sweetened beverages. Because of the low-sugar requirements in the WELL rating system, only one sugary soda remains in the vending. The remaining have all been switched to diet sodas, all of which have artificial sweeteners that are generally associated with their own health concerns. This will likely evolve over time as new versions of each rating system are published simply because the rating frameworks are still so new to the industry.⁶ It should be noted that the smaller cans of soda would comply, but the current vendor is unwilling to provide these based on financial concerns of them not selling in a timely manner.

people that were drinking enough water each day were already aware of that need and their habits did not change. The real impact was noticed on the employees that were not drinking sufficient water each day. Of those that had previously noted that they only drank 2 or less cups of water a day, half increased their water consumption on a regular basis.

3.7 Mental Health The WELL rating system has several measures in place to address mental health, with an entire category named “Mind.” Fitwel’s primary response is to simply provide a variety of spaces that all positively affect mental health—a simple yet effective practice. The LEED rating system does not directly address mental health but does incentivize strategies such as occupant views to the outdoor environment. Fitwel also uniquely addresses mental health by ensuring that adequate exterior safety measures are implemented such as lighting, something most designers assume will be in place.

The new office has water filtered by Reverse Osmosis, with a blend back filter that reintroduces trace minerals into the water for taste. It also has UV sterilization. More than 95 percent of occupants noted that they liked the water provided by the office, compared to 78 percent of the old office. The former office offered filtered water, but it was not filtered to the same level of the new office.

When asked about the average quantity of water consumed by individuals, the number that drank 6 or more cups of water each day changed very little. The

Fitwel’s encouragement of providing a variety of spaces were greatly considered. Points are earned for providing spaces such as a designated exercise room, a walkable outdoor space, a garden, and a lactation room for nursing mothers. Introducing these strategies required planning and flexibility on part of the occupants, but has been effective in providing multiple needed amenities as seen in Figure 7. Just over 92 percent of surveyed employees believe that a variety of workspaces is available for carrying out diverse tasks. That is a considerable improvement from the previous office, with only 53 percent of employees agreeing in the preoccupancy survey, where a lactation room was available.

A significant 93 percent of respondents believe that the new office offers spaces that encourage collaboration, a factor that should be noted if concerns arise about employee productivity. A balance of amenities and productivity can be achieved, providing employees flexibility, as demonstrated in Figure 8.

WELL sets the reduction of stress as a goal on numerous features. A 2018 study noted that “stressrelated disorders was significantly associated with an increased risk of autoimmune disease.”⁷ Such measures attempting to reduce stress and improve human health have certainly had effect. Altogether, stress appears to have decreased. The number of highly stressed

Figure 6: A noticeable change with vending satisfaction is visible post-occupancy.

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Figure 7: Additional space types have brought enhanced collaboration and interaction.

Figure 8: The Multipurpose room serves various functions but requires take-down and setup time.

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Figure 9: Perceived stress shifted downwards, demonstrating a generalized reduced stress.

individuals decreased by 24 percent. Significantly 7 of the 163 respondents in the post-occupancy survey noted nonexistent levels of stress, while none of the preoccupancy survey’s 154 employees claimed to be stress free as demonstrated in Figure 9.

in each rating system. Still, it required an elevated level of coordination to pursue and balance each framework’s unique requirements. If the decision had been made to only pursue one or even two of these rating systems, notable amenities, benefits, and impacts would be missing.

The introduction of designing for wellness is imperative for occupant health, and directly meets one of the elements of the triple bottom line—people. Few architectural projects have been completed that are not people-centric. The American Institute of Architects (AIA) even requires annual education focused on Health, Safety, and Welfare to maintain the professional credential, emphasizing that building occupants should be the primary concern.

4.0 Conclusion In recent decades, the resurgence of sustainability as an integral element of design has altered and continues to challenge, if not revolutionize, the architectural practice long-term. These strides are impactful and wide-spread and have generally been accepted as a positive direction.

The very concept of sustainability is altruistic and selfless, as the primary focus grows to include operating responsibly, reducing emissions, and improving occupant health and sense of well-being in a way that “meets the needs of the present without compromising the ability of future generations to meet their own needs.”⁸

With the increased focus on occupant well-being, under the umbrella of sustainability, building occupants can live healthier, or at a minimum, feel that they live healthier. All three rating systems (LEED, WELL, and Fitwel) impacted this project in unique ways, elevating the understanding of sustainable design and how that directly impacts

The three rating systems generally worked well together, with direct synergies or credit equivalencies noted

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the people inside of the office of Perkins&Will Dallas.

Evidence shows raised awareness of both wellness and sustainability on a broad level by employees. Happy employees have stronger loyalty to a company when they believe that company has invested in them as individuals.

When a business’ number one resource is its employees, that seems like a choice that will impact retention, productivity, and general morale.

References

Despite these efforts and design knowledge of wellness, a danger lies in designing for wellness in a silo. Is designing for wellness a sustainable practice? Not if it is done without incorporating the other elements of the triple bottom line, keeping a simultaneous balance with profit and planet. Wellness design can use more energy and produce more waste if holistic sustainable efforts are not discussed. The new Dallas studio office of Perkins&Will worked to pursue sustainable design and wellness design simultaneously, and we have yet to work on a project interested in pursuing a wellness centered certification that has not also pursued some level of sustainable certification.

[3] Flores, Y., (2017). “Contributing with Voluntary Certification Systems: A Case-Study Evaluating Knowledge Gaps Between Design Professionals and the Well Building Standard”, Thesis, The University of Texas at Austin.

[1] International WELL Being Institute, (2020). WELL v1 Building Standard, Retrieved on 02/2020 from https:// www.wellcertified.com/certification/v1/standard.

[2] Center for Active Design, (2020). Fitwel Standard, Retrieved on 02/2020 from https://www.fitwel. org/standard.

[4] Chang, T. , and Kajackaite, A., (2019). “Battle for the Thermostat: Gender and the Effect of Temperature on Cognitive Performance”, PLOS One, https://doi. org/10.1371/journal.pone.0216362.

[5] Kim, J., and de Dear. R., (2006). “Workplace Satisfaction: The Privacy-Communication Trade-Off in Open-Plan Offices”, Journal of Environmental Psychology, Vol. 36, pp. 18-26.

[6] Obrecht, T., Kunic, R., Jordan, S., and Dovjak, M., (2019). “Comparison of Health and Well-Being Aspects in Building Certification Schemes”, Sustainability, Vol. 11, No. 9, 2616.

Acknowledgments Special thanks are given to Courtney Johnston, Tarah Griffis and Nirmala Srinivasa for their efforts in the design and construction administration of the project that required a heightened level of coordination to implement strategies and create solutions that met all rating systems discussed in this article. Additional thanks are also given to Ricky Boler and the Balfour Beatty team.

The pursuit of three separate certifications on top of a historic restoration made for a challenge for everyone.

These efforts could not have been accomplished without his efforts to coordinate everything on top of his other responsibilities.

[7] Song, H., Fang, F., and Tomasson, G., (2018).

“Association of Stress-Related Disorders with Subsequent Autoimmune Disease”, Jama, Vol. 319, No. 23, pp. 2349-2450.

[8] United Nations, (1987). Report of the World Commission on Environment and Development, Report, Retrieved on 11/2020 from https://www.un.org/ga/search/view_doc. asp?symbol=A/42/427&Lang=E.

It is also important to thank Mary Dickinson who championed the decision to pursue all three certifications.

Her efforts on vetting materials against Perkins&Will’s Precautionary List pioneered multiple strategies and efforts that helped ensure a healthy indoor environment for all involved. Numerous lessons learned have already been incorporated into multiple projects as the result of these efforts. This project would not have happened like it did without her continued efforts.

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04 Planning for the Best-Case Scenario: Infectious Pandemic Surge and the Intensive Care Unit Program Susan Ealer, NCARB, LEED AP® ID+C, susan@susanealer.com

Abstract We currently face a third wave of a COVID-19 Pandemic that threatens to incur more devastating losses than the previous two. The need for an Intensive Care Unit (ICU) that is planned for response to an infectious pandemic surge in a manner that is financially and operationally practical to implement is urgent at present.

The following Space and Functional Programs, outlining the recommendations for a 12-Bed Infectious Pandemic Surge Intensive Care Unit, draw on hours of research gathered from official guidelines, task force recommendations, scientific reports, media coverage of the COVID-19 Pandemic, and a series of interviews with front-line providers, patients, experts, and Perkins&Will healthcare leaders actively working to find solutions to overwhelming problems faced during the first two waves of the pandemic.

To meet the overall additional space need for a 12-Bed Intensive Care Unit to practically respond to an infectious pandemic surge, a modest eight percent increase in departmental gross square footage (over the size of a traditional unit) must be allowed for. To achieve this, the assets provided in a traditional Intensive Care Unit design must be leveraged to provide specialized functions during times of infectious pandemic surge. This means that many of the components that make up the regular Intensive Care Unit will have dual-functions—one during regular operations and one during infectious pandemic surge.

Keywords: infectious, pandemic, intensive care unit, surge capacity, COVID-19, medical planning

1.0 Introduction This investigation is a response to the great need for critical care infectious pandemic surge preparedness painfully exemplified by the 2020 March through June COVID-19 response in New York City. Despite numerous quiet warnings published by disaster preparedness organizations and think tanks over the last ten years, outlining a coming infectious respiratory pandemic resulting in dire shortages of life-saving equipment like personal protective equipment (PPE) and ventilators, we simply are not ready. During the 2020 spring surge, hospital ICU’s overflowed, many people were turned away, and others who would normally be treated in the ICU chose the risky option of self-treating at home to avoid potentially dangerous conditions at the city’s

hospitals. When hospitals become places to fear instead of places to turn to in times of need, we must change the paradigm.

1.1 What Are We Planning For? Determining this might seem simple and obvious but in fact, this task is exceedingly difficult. One could argue that this is the most difficult task in planning. The first part of this investigation seeks to define the parameters for an Infectious Pandemic Surge Space and Functional Program for an Intensive Care Unit—something practical and evidence based that clients and designers can learn from, can afford, and can implement.

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1.2 Developing and Communicating the Planning Strategy

2.2 Interviews Subsequent to the first wave of COVID-19 infections referenced above, interviews were conducted with frontline providers, patients, experts, and healthcare design leaders who were actively involved with clients and other design industry professionals in developing responses to the needs generated by the COVID-19 Pandemic.

When trying to plan for a complex, clinical response to a rapidly spreading pandemic caused (in the case of COVID-19) by an unfamiliar pathogen, this task becomes exponentially more difficult.

The objective of this research was to provide helpful, practical recommendations, informed by expert experience and clinical practice. The study focused on the simplest module—one 12-Bed Intensive Care Unit (ICU) and, by extension, some of the pieces that link to the unit. These include the patient room and some elements of the hospital as a whole including—patient circulation, waiting rooms, operating rooms, etc.

2.2.1 Interviewees Front-Line Providers nj Physicians treating COVID-19 patients nj Nurses treating COVID-19 patients nj Hospital Department Directors

The recommendations outlined in this document are presented in the form of a Functional Program, which includes prescriptive recommendations and diagrams, and a Space Program, which lists all required functions by category and outlines their size in terms of square footage.

COVID-19 Patients Experts nj Principal—technology consulting firm nj Senior Director—medical equipment planning consulting firm, Registered Nurse, and former Operating Room Manager

Additionally, included in the Functional Program are— Case Studies, Contributor Wish Lists, excerpts from interviews, and expert input on specialized topics (i.e., logistics, mechanical systems, technology, equipment).

nj Executive Vice President—logistics consulting firm Perkins&Will Healthcare Leaders

2.0 Methods

nj Regional Healthcare Practice Leader

2.1 Research/Data Gathering

nj Medical Planner

This article incorporates hours of research gathered from official guidelines, task force recommendations, scientific reports and the work of other people trying to answer related questions. It also incorporates media coverage of the COVID-19 Pandemic, which is active during the writing of this paper, and lessons learned from participation in the following task forces that worked aggressively to create surge beds during the first wave of infections that hit the US from March through June in 2020:

nj Healthcare Operations + Strategic Planning Executive, Registered Nurse, and former Chief Nursing Officer nj Regional Healthcare Director nj Senior Medical Planner, Registered Nurse, and former Emergency Department Director

2.2.2 Interview Format The interviews followed a documentary-style format which is designed to be spontaneous, investigative, and exploratory. Interviews were based on a framework of standard questions but were structured to allow the conversation to take its course based on the interview subject’s answers and expertise.

nj Governor Cuomo’s Greater New York Hospital Association Task Force with a focus on retrofit of alternate care sites nj The Los Angeles Perkins and Will Office COVID-19 Task Force with a focus on modular facilities.

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Step 3: Develop solutions which address needs and incorporate the most innovative thinking available in the industry.

The questions were designed to capture the following: nj The subject’s recent personal experiences coping with the COVID-19 Pandemic

Step 4: Vet the solutions with the users and experts involved. In this case, vetting involved follow-up conversations and reviews of the draft report.

nj Lessons learned during the recent COVID-19 Pandemic with regards to patient/staff wellbeing, operational procedures, infection control and surge capacity nj Recommendations for adapting ICU design and overall pertinent hospital support infrastructure to respond to a future infectious pandemic.

3.0 Identifying the Need 3.1. Infectious Pandemic Surge

Some standard questions included:

3.1.1 Infectious Pandemic—What to Prepare for Next

nj What crucial lessons did you learn about clinical practice, operations, and space needs during the recent COVID-19 Pandemic? What worked and what did not work?

Recent large scale infectious events have included such disparate pathogens as HIV/AIDS, Ebola, those generated by the threat of bioterrorism, and COVID19. Designing a 12-Bed ICU that has the capacity and flexibility to handle a wide variety of potential pathogens, with special emphasis on the most likely pathogens, is the strategy advocated by this program.

nj Separation of infectious patients from the rest of the population within a hospital is key. This includes getting them to the unit(s) and allowing them to access diagnostic and treatment facilities that cannot be brought to the bedside. What tactics do you see as being successful in this regard?

It is chilling to read the 2017 Johns Hopkins Bloomberg School of Public Health Center for Health Security’s paper, The Characteristics of Pandemic Pathogens, on the heels of New York City’s recent COVID-19 pandemic surge. The report defines Global Catastrophic Biological Risk (GCBR) pathogens as microorganisms (natural or created) that could lead to sudden, extraordinary, widespread disaster beyond the collective capability of national and international governments and the private sector to control.1 GCBR’s have the capacity to cause great suffering, loss of life, and sustained damage to political and economic infrastructures. The novel coronavirus checks all the boxes for a GCBR-Level Pandemic Pathogen.

nj What are the biggest challenges in terms of supplies and equipment in situations like these? nj What do you think are the most important functions/ elements that should be provided in a 12-Bed Infectious Pandemic Surge ICU Unit? In an ICU patient room? nj What is the most successful way to support patients, families, and staff? nj What is on your wish list going forward?

2.3 Planning Process

In determining which organisms are likely candidates for GCBR’s, it is important not to rely on historical pathogen list-based approaches, such as creating a list of the 10 worst pandemics of all time.1 One of the key criteria for a virulent GCBR is that there is no known cure. This would rule out something like the Bubonic Plague, which can now be cured with antibiotics, or even Malaria, which is hypothesized to have killed half of all humans who have ever lived over time.¹ Figure 1 depicts a list of the most likely candidates for the next pandemic.

The development of the Space and Functional Programs followed a traditional Medical Planning User Group Process.

Step 1: Interview the users (the people who are going to use the end-product) to determine their needs.

Step 2: Interview experts and leaders in the field for best practices and recommendations.

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Figure 1: The most likely candidates for the next pandemic.

3.1.2 Surge

As a GCBR-Level Pandemic Pathogen, COVID-19 spread quickly through respiratory transmission during its incubation period in a population with no immunity.

Front-line physicians and hospital staff, who had never encountered anything like this before, took heroic measures but were unable to stem the tide of patients dying in their care.

Surge is defined as a sudden, unanticipated escalation in health system demand caused by exceptional events.2 Surge events affect critical care in a variety of ways depending on the onset, impact, and duration of the incident. Sudden impact events tend to affect Emergency Department services more acutely but the impact to critical care and Surgical Services can last for days or even weeks afterward. Slow-onset disasters, like hurricanes or pandemics, pose the challenge of maintaining a sustained critical care response over weeks and months—sometimes even years. These events tend to have more impact on the ICUs as patients are transferred from the Emergency Department and may need ongoing care for an extended period of time.3

Shortages of Staff/Supplies: In the face of the massive surge, New York hospitals quickly ran short of staff and supplies. At one prominent New York hospital, leaders estimated that about a third of the doctors and nurses were out sick. Inundated critical care units depleted the hospital’s inventory of key essentials like protective plastic gowns, sedatives for patients on ventilators, and key blood pressure medications. The sense of tragedy was heightened even further when members of the staff circulated an online video showing a forklift hoisting a body into a refrigerated trailer right outside the hospital.⁵

3.1.3 Case Study: Infectious Pandemic Surge—New York City, COVID-19 Overwhelming Loss of Life: Estimates put the number of pre-COVID ICU beds in New York City at 1,600. As of June 28, 2020, the City had 212,000 confirmed cases of COVID-19 and nearly 55,000 patients had been hospitalized. A substantial percentage of these patients required critical care. Lower-income communities were especially afflicted.4

Equipment/Infrastructure Failures: Critically ill patients’ need for dialysis and for ventilators far exceeded hospitals’ baseline capacities and the available supply chain inventory. Oxygen tanks were strained or malfunctioning.⁶ One private hospital in the City had to be partially evacuated as its oxygen supply broke down.

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3.2 Planning for Chaos

and order are inextricably intertwined. In the midst of order, there is chaos but more importantly, in the midst of chaos, there is order.8 Planners can leverage this order to incorporate preparedness into their space and functional programs.

“No strategist in a million years could have predicted that New York City would be crippled to the point of needing tents in Central Park because every ICU bed was filled with COVID patients.”

With a pandemic, patient volumes are inherently unpredictable. In the spring of 2020, the patients being treated at New York Presbyterian, a 1200 bed hospital, were 100 percent COVID-19 ICU acuity level patients at one point. The existing framework for surge response to pandemics such as these is a continuum with thresholds that distinguish conventional surge from contingency surge and crisis surge.9, 10 The continuum is recognized by such organizations at the World Health organization (WHO) and the Centers for Disease Control and Prevention (CDC). Figure 2 presents a matrix of factors that serve to define the continuum thresholds:

- Healthcare Operations + Strategic Planning Executive, Registered Nurse, and former Chief Nursing Officer

3.2.1 Chaos In the face of an infectious pandemic surge, how does one plan for the chaos? The type of pandemic, its magnitude, and where and when it will occur are all unpredictable. Pandemics can draw down local and global resources in complex and unexpected ways.7 Experts in chaos theory, however, point out that chaos

Figure 2: Surge response continuum.

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nj Conventional surge response targets are generally achieved using available resources.

nj Tiered staffing structures were implemented, with ICU doctors and nurses leading teams of non-ICU providers. This approach significantly expanded capacity to deliver high-quality critical care.

nj A contingency surge response usually requires critical care to be provided in non-traditional hospital areas (such as Post Anesthesia Care Units) and must incorporate community or regional resources.

nj Manual proning (turning a patient over or turning a patient on their side) was performed under the direction of surgical teams with experience performing the maneuver in the operating room.

nj A crisis surge response, like the one seen in New York City during March through June, in 2020, forces a portion of critical care outside the hospital setting into temporary alternate care sites and relies on national stockpiles and networks of resources

nj Anesthesia physicians and nurses, who were not working due to a shut-down of the City’s operating rooms, performed endotracheal intubations and obtained vascular access. This liberated ICU physicians from those tasks and thus expanded their capacity for patient care.

3.2.2 Case Study: Planning for Chaos - New York City, COVID-19

Creative Logistics: The hospital supply chain is a very complex network of resources, which includes distributers, group-purchasing organizations, integrated delivery networks, hospital supply chain organizations and physicians. The complexity brings performance risk along with it. The current operational just-in-time approach, where hospitals rely on daily deliveries, failed during the New York City COVID-19 surge and creative logistical methods were employed to provide life-giving items like ventilators and PPE: passenger aircrafts were put into freight service, production lines were converted over to produce needed medical products, and communities banded together to hand produce masks and other products.13

Rapid Expansion of Capacity: As the number of cases rose in New York, hospitals carried out plans to greatly expand critical care capacity. At baseline, one NY hospital network had an ICU capacity of around 300 beds. At the peak of the spring 2020 COVID-19 surge, the network was caring for 1,000 ICU patients. A hospital in the Bronx increased from its baseline ICU capacity of 34 up to a capacity of 195.

Hospitals in the New York metropolitan area took the following measures to increase surge capacity during the first wave of the COVID-19 pandemic: nj Primary Intensive care unit (ICU) spaces were identified and upgraded as needed nj New ICU spaces were created in emergency departments and other inpatient units.

3.3 Why the ICU? “The recent pandemic surge in New York City was the most devastating medical scenario I have experienced in 40 years. We were dealing with a virtual tsunami level of illness with incredible mortality associated with it.

During the peak, our facilities had transformed into large ICUs. There were 2700 COVID patients in the hospital, 800 of those were ventilated in the ICU. If you don’t have enough ICU beds, you can’t get through it. We’ve crossed the Rubicon on this. We can’t go back to where we were.”

nj Procedural areas such as endoscopy suites, perioperative suites, post-anesthesia care units, and operating rooms were identified as flex ICU spaces because elective procedures were being deferred. nj Patients were also transferred between hospitals to reduce strain.11 Staff Recruitment: Not only were beds in desperately short supply, but there were not enough staff members to provide care for the patients flooding into New York City hospitals in unprecedented numbers. Staff was recruited from other states to help meet the need, doctors and nurses were called out of retirement, and hospital caregivers got creative.12 The following strategies were implemented:

- President and CEO of a major New York City hospital

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3.3.1 The ICU is Crucial in A Pandemic

Another issue with these sites is operational. Someone needs to run them and to care for the patients. Hospitals and Health Systems must take them on and they simply do not have enough staff, especially during a pandemic, to send groups to sites far away from the parent hospital.

Whether designed from scratch or retrofitted, the ideal scenario for most hospitals is to be able to handle the surge within the hospital itself.

After the Emergency Department, the ICU is the main line of defense in a pandemic response. ICUs provide care to patients with severe or life-threatening illnesses and injuries which require constant care, close supervision from life support equipment, and medication to ensure normal bodily functions. Studies show that 22 percent of all deaths in the U.S. occur in the ICUs.14

Converted Chicago Hospital: The four week-long conversion of a shuttered Chicago Hospital to a Tier 2/2A/3, 585 bed, ICU Level, COVID facility was a truly heroic feat achieved by the design, construction, and management teams involved. The conversion provides desperately needed surge capacity for the Chicago area going forward.

The Intensive Care Unit is a specialized hospital unit dedicated to the care of patients requiring life-support and at extremely high risk for organ failure and death.

Death and dying is a daily occurrence in the ICU, forcing the teams to function in a highly charged emotional environment characterized by persistent grieving and moral distress.

As an older facility built for a different function, the Alternate Care Site faces some challenges not found in an ICU located in a more modern, operational hospital buildingâ&#x20AC;&#x201D;these include use of ward configurations instead of private rooms and line-of-sight challenges.

With regards to the physical environment of the ICU near constant alarms, uneven lighting, poorly placed equipment, and space limitations can mean that the physical environment is at best not helpful and at worst harmful to the goals of team-based critical care.14

4.0 Recommendations

3.3.2 Case Study: ICU vs. Alternate Care Site

4.1 Overall ICU Planning Guidelines for an Infectious Pandemic Surge

From March through June of 2020, the need for ICU beds in New York City was so great that several non-hospital Alternate Care Sites were set up to care for ICU patients.

One of the challenges with these sites is that the facility construction and configuration is sub-clinical and does not meet code or the current best-practices of critical care. Among these were: the Javitz Convention Center, The United States Naval Service Comfort Hospital Ship, and the Central Park Tent Hospital.

The following overall ICU planning guidelines draw from chaos planning protocols and infectious pandemic surge response recommendations, from lessons learned during case studies and user interviews, and from design industry standards and best practices. These guidelines form the guiding principles that shape the planning recommendations outlined in this article. They are outlined in Figure 3.

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Figure 3: Pandemic measure recommendations.8, 9, 15

4.2 ICU Considerations

feedback from front-line clinicians during the first wave of COVID-19.

4.2.1 Unit Planning ICU beds, and by extension the ICU itself, were the most in-demand resource during the spring 2020 COVID-19 surge. The ICU is the most fundamental module in longâ&#x20AC;&#x201C; term critical care treatment (compared with the shortterm care received in the Emergency Department). It is a complex set of spaces that serve to support life-saving care, the people who are saving lives, and those being saved.13 The extreme nature of day-to-day ICU practice has sorely tested ICU design over the years. The COVID19 surge served to test it even further.

4.2.2 Case Study: ICU Space Allocation in Award Winning ICUs of the Last Two Decades Study Scope: The study includes a set of 25 adult ICUs that were awarded between 1993 and 2012 by the Society of Critical Care Medicine (SCCM), the American Association of Critical Care Nurses (AACCN), and the American Institute of Architects/Academy of Architecture for Health (AIA/AAH) for their efforts to promote the healing of critically ill and injured patients through the design of the critical care unit environment.16

It is important that recommendations for the adaptation of the 12-Bed ICU Unit made to accommodate a future infectious pandemic surge be responsive to the need.

In addition, suggestions should enhance the bestpractice unit design rather than replace elements that successfully support patient care and have taken years to develop. The following recommendations incorporate studies of the evolution of ICU design as well as crucial

Type: The racetrack layout has been the most dominant unit type among award winning ICUâ&#x20AC;&#x2122;s during the last two decades, since it provides more space and perimeter wall for more patient rooms with natural light and outside views, it accommodates more compact and centralized support and helps reduce the physical distance from patient rooms to support areas. Some

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Size: An ICU must be large enough to accommodate appropriately sized patient rooms and support areas but small enough to allow constant visualization of ICU patients by care givers and to ensure that care givers are fully aware of all the people and activities on the floor.

Additionally, the size must support short travel distances and noise reduction.

studies show that radial units perform better than single and double corridor units due to better visibility and shorter walking.16 Figure 4 shows diagrams of some of the most popular historical ICU layouts.

The SCCM Guidelines recommend maximum 8-12 beds per unit for better observation. In general, larger ICUs with more beds have more hospital acquired infections.

The study shows the average number of beds for all the units was 24, which is a much higher number than the numbers recommended by SCCM.16

4.2.3 Proposed Infectious Pandemic Surge ICU Configuration Proposed 12-Bed ICU Unit Overall Configuration: The number of beds required is client dependent so solutions starting with a 12-bed unit that could be expanded to 24 and 48 beds offers flexibility and maintains appropriate staffing ratios of nurses to beds. The proposed 12-Bed ICU Unit maintains an overall set of configurations that allow for efficient, flexible, and effective operations that translate into optimal patient care. These are outlined in Figure 5.

Figure 4: ICU configurations, including racetrack layout.

Figure 5: Proposed ICU configuration.

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Proposed 12-Bed ICU Unit Diagram:

4.2.4 The 12-Bed ICU Unit Contributor Wish List

The Proposed Infectious Pandemic Surge 12-Bed ICU Unit diagram, which will be discussed in detail in this section, represents the determined functional and space planning requirements based on the research and interview data acquired during this study. Figure 6 shows regular functions, as well as pandemic surge functions.

Some considerations are listed below:

The 12-Bed ICU Unit Contributor Wish List, shown in Figure 7, represents the three infectious pandemic surge unit design features most requested by the users, experts, and design leaders interviewed while researching this article. These requests, along with a host of other recommendations and research data, informed the Proposed 12-Bed ICU Unit design.

nj Patient Surge: It is planned to allow for a surge capacity of 100 percent - or a doubling of patient beds, which are accommodated at two per patient room.

4.2.5 Addressing 12-Bed ICU Unit Wish List Item #1— Provide Respite Room

nj Support Surge: Staff support, and clinical support areas are configured to flex up during surge, allowing for more supplies and more caregivers to be on the unit.

Diagram—Proposed 12-Bed ICU Unit: Staff Support: Figure 8 shows design strategies for the proposed ICU design that support medical staff. During a pandemic it is essential to maintain the health and safety of the people who are saving lives. The front-line hospital workers who reported to work daily during the 2020 March through June COVID-19 surge in New York City faced overwhelming horrors while treating patients, friends, and colleagues. The stress of treating people with an out-of-control mystery virus took an enormous toll on the health of these workers.

nj Isolation Unit: The unit planning supports the conversion of the unit to a self-contained isolation unit during infectious pandemics. nj Safety: Other important infection control and staff amenity features that serve to protect staff as well as patients are given a high priority.

Figure 6: Proposed ICU layout.

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Figure 7: ICU contributor wish list.

Institutions like Mount Sinai Beth Israel in Manhattan implemented make-shift respite rooms for staff on hospital grounds. Self-reported stress dropped 60 percent after just 15 minutes in the rooms.17 The Proposed ICU design incorporates the following features in support of the staff:

and the other is a flex consult room located near the public waiting room. nj On-Call Rooms: Are provided on the floor for Staff who need to sleep between shifts.

Staff Work:

Staff Respite:

nj Work Areas: Are sized for social distancing or additional staff.

nj Permanent Staff Lounge: A permanent Staff Lounge is provided out of the way at the end of the unit with direct access to an outdoor terrace. (see 4.4.3 Hospital Contributor Wish List—outdoor space is another highly requested item for reducing stress).

nj Flexible Work Zones: Nurse Stations back up to flexible work zones that allow for a variety of configurations. nj Caregiver Substations: Provide enhanced facilities for charting and patient care (see 4.3.4 The ICU Room for more information).

nj Flex Staff Lounge (off Unit): A second pandemic flex Staff Lounge is provided off the unit in the waiting room space which will not be used during a surge (visitors are not allowed inside the hospital). Providing respite off the unit is key to limiting distractions.

Keeping it nearby allows staff to return to the unit quickly if needed. (Note: this space could also be used for additional workspace).

4.2.6 Addressing 12-Bed ICU Unit Wish List Item #2—Add More Isolation Units Current ICU design best practices and regulatory standards provide for one or two negative pressure isolation rooms per unit to house the small number of infectious patients that enter the hospital for treatment on a daily basis. During an infectious pandemic, this

nj Quiet Rooms: Two quiet rooms are provided as well.

One is on the unit (can also flex as a lactation room)

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Diagram—Proposed 12-Bed ICU Unit: Isolation

number becomes woefully inadequate. For this reason, hospitals are increasingly interested in designing whole units with the ability to flex into negative pressure isolation units in emergency situations. This can be a challenging and expensive proposition. Even more challenging is the recent hospital demand for retrofits that will allow existing units to flex.

The proposed ICU, shown in Figure 9, is designed to allow the conversion of a 12-Bed ICU Unit into an isolation unit during an infectious pandemic. nj Mechanical (HVAC) System: The unit HVAC system must be separate from that of the main hospital and contain the proper filtration (see Case Study below).

The Case for Isolation Units

nj Ante Room: An ante room is provided at the entry and a smoke barrier is installed around the unit to ensure that the proper air pressure is maintained, and that no infection can spread beyond the unit itself.

nj Respiratory Transmission: The 2017 Johns Hopkins Bloomberg School of Public Health Center for Health Security paper, The Characteristics of Pandemic Pathogens, states that the respiratory route is the mechanism of transmission most likely to lead to pandemic spread. This is because interventions to interrupt this method of spread are more difficult to implement. Isolation Units are one such method.

nj Dedicated Elevator: A dedicated service/patient elevator is provided to minimize mixing infected patients with the general population and minimize outside incursions into the unit.

nj Cohorting: Placing patients infected with the same pathogen in the same unit is recommended by the CDC, WHO, Johns Hopkins Bloomberg School of Public Health.

nj Infection Control: Additional infection control facilities are provided for gowning rooms (flexed Offices) and handwashing stations.

nj PPE: Some clinicians and health organizations feel Isolation Units can reduce the need for donning and doffing each time a caregiver enters a patient room.

Some clinicians feel that patient safety mandates continuing this practice even in Isolation.

Figure 8: ICU staff support.

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Figure 9: ICU design for the Isolation Unit.

4.2.7 Case Study: Retrofit Test Model

Successful

Isolation

Unit

since the onset of the COVID-19 pandemic and deserves further study.

The concept of a Flex Isolation Unit that can function as a regular unit until needed during an infectious pandemic has not yet commonly been put into practice. There are a few hospitals today which have such units, including Chicagoâ&#x20AC;&#x2122;s Rush University Medical Center designed by Perkins&Will in 2012. Developing a cost-effective way to retrofit an existing unit to meet the requirements of an isolation unit is something that is much in demand

In 2015, the Association for Professionals in Infection Control and Epidemiology conducted a study whereby an existing ICU unit was temporarily retrofitted to create an isolation unit.18 Air flow measurements were taken and found to be within an acceptable range for preventing infection spread.18 Please see Figure 10. Some useful take-aways are as follows:

Figure 10: Successful Temporary Isolation Unit retrofit test model.18

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nj Functioning Hospital: A functioning hospital in the San Francisco Bay Area was used.

not be worn into more than one room.19 While reusing PPE when treating more than one patient may continue to protect the caregiver, it will expose the patient to previous patients’ infections. In the case of COVID19, it has been shown that increased viral load carries increased morbidity.20

nj Chosen Ward: The chosen ward was located on a top floor where it could be effectively isolated. It had an existing dedicated air handling unit, a dedicated bathroom exhaust system, and a firewall separating it from the rest of the hospital.

Placing multiple PPE cabinets and disposal bins between rooms (instead of forcing care givers to don and doff in a gowning room that may be far from the patient bedside) considerably improves the workflow for staff working in those rooms. The amount of PPE gear required can be considerable depending upon the infection, as shown in the chart below, and must be accommodated for sufficiently in the design.21 Figure 11 depicts sample PPE requirements.

nj Modifications: The Air Handling Unit (AHU) was set to 100 percent outside air and 100 percent exhaust.

HEPA-filtered negative-air machines were operated in the ante room created at the entry. The fire doors were closed to seal the unit off.

4.2.8 Addressing ICU Wish List Item #3—Give Us PPE Cabinets

Diagram—Proposed 12-Bed ICU Unit: Clinical Support

Best practice dictates that staff must put on fresh PPE each time they enter an infectious person’s room. Upon leaving, the used PPE must be taken off and disposed of properly (or cleaned and re-used). The PPE should

Figure 12 shows design strategies for clinical support: nj Distributed PPE Cabinets (see 4.3.4 The ICU Room for more information)

Figure 11: Required PPE chart for sample illnesses.19, 21

Figure 12: ICU design strategies for clinical support.

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Figure 13: ICU technology solutions.22

nj Enlarged Clinical Support Spaces: One of the biggest lessons learned during the COVID-19 pandemic is that some of the clinical support spaces are not currently sized to handle pandemic volumes. Supply rooms are the obvious culprits, but the environmental services closets and the soiled utility rooms also need to be bigger than the current code requires in order to handle the volume of waste generated in a crisis event.

4.2.9 ICU Unit Technology Solutions In addition to developments in clinical planning with regards to accommodating an infectious pandemic surge, new technologies are being developed every day to enhance and facilitate care. One of the most important considerations in technological advancement as it relates to healthcare is that it needs to respond to a particular need. Technology cannot be implemented for technology’s sake. It needs to support the people who use it. Some recent new ICU unit technology solutions are outlined in Figure 13.

In the Proposed 12-Bed ICU Unit Plan, clinical support spaces are up-sized approximately 8-10 percent (see section 5.3 Space Program). Additional flex pandemic storage is provided off-unit in a conference room.

4.3 The ICU Room

nj Disneyland Concept: Major supply storage and waste rooms are back-fed through a dedicated elevator lobby by a dedicated elevator allowing material to be transported without coming into contact with patients.

4.3.1 Proposed Infectious Pandemic Surge ICU Room The proposed Infectious Pandemic 12-Bed ICU Unit is planned to allow for a surge capacity of 100 percent - or a doubling of patient beds, which are accommodated at two per patient room. Because the cost of hospital construction can be upwards of $1,000 per square foot (varies by state), increasing the size of the patient room

nj Imaging Alcoves: Larger imaging alcoves are provided to make sure portable imaging can be provided on the unit, keeping fragile, infectious patients in their rooms.19

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Figure 14: Proposed ICU room configuration.

to accommodate two patients in a surge situation can be prohibitive. For this reason, configuring the room to work for two patients as well as one becomes imperative.

Diagram—Proposed ICU Room Configuration: The proposed ICU Room configuration, shown in Figure 14, accommodates two patients as follows:

When doubling-up patients in a room, it is important to remember that there may be half a dozen people in those rooms at any one time: nurses, doctors, respiratory therapists, someone doing dialysis, etc. Code required clearances may be relaxed during an emergency but functional clearances must be maintained. During the spring 2020 COVID-19 surge, family sleep couches, side tables, and guest chairs were moved out of the rooms to allow caregivers space to work.

nj Maintaining Proper Clearances: Facility Guidelines Institute (FGI) and the California Office of Statewide Health Planning and Development (OSHPD) clearances for one bed are maintained. Relaxed clearances, which are functional and historically allowable by regulatory agencies, are maintained for two beds.23 nj Toilet Room Configuration: This is modified to ensure clearances for two beds. It is located outboard (on the

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outer wall) to provide maximum visibility by caregivers from the hallway.

4.3.2 Case Study: ICU Room Challenges—New York City, COVID-19

nj Equipment: Space for infectious pandemic equipment (ventilators, dialysis, etc.) is provided.

Alcoves Between Rooms: The PPE shortage due to supply chain failure, along with the unknown nature of COVID19 transmission at the time, caused caregivers to employ extraordinary measures to stay out of the patient rooms.

Staff separated control boards from ventilators so they could adjust their settings and monitor patients from the hallway and moved what equipment they could outside the patient room doors, adding leads that snaked across floors. This created dangerous tripping hazards that could not only cause staff injury but endanger patient care if the plug for a lifesaving piece of equipment was pulled out of the wall.

Diagram—2 Patients in 1 Room: Providing Services: Doubling up on additional service infrastructure (booms, headwalls, etc.) can also be prohibitively expensive for health systems to consider. Figure 15 shows a diagram for design strategies that can be used to provide services for two patients in one room.

To mitigate cost, additional outlets can provided on the primary patient’s delivery system (headwall, boom, in-wall unit) or an in-wall unit can be added directly over the secondary patient bed location to provide the additional services. Consideration must be given to making sure the leads for the equipment can reach the patient.

Equipment: nj Dialysis: Due to the unknown nature of COVID-19, the need for dialysis in COVID patients surprised hospitals

Figure 15: Proposed services delivery for two patients in one room.

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during the spring 2020 surge and they did not have enough machines to treat them. Dialysis services are vital to the treatment of many pandemic conditions.

Often dialysis is provided through an outside contract.

The service provides portable dialysis machines that can be wheeled into the rooms. Because dialysis uses specially treated water, it is important to make sure the mobile dialysis machines have self-contained water reservoirs. There also may be stations in the hospital where the machines can be refilled.

same ventilator settings. Medical equipment planners state that hospitals ideally should plan for providing at least one ventilator per room. Unfortunately, most current equipment budgets will not accommodate that. The medical equipment industry is developing inexpensive ventilators with more capacity in the wake of COVID-19.

4.3.3 The ICU Room Contributor Wish List

Ç&#x152;â&#x20AC;&#x201A; Ventilators: Ventilators are key to treating lifethreatening respiratory infections. During the spring 2020 COVID-19 surge, many hospitals that were short on ventilators retrofitted their existing machines to support two patients. One of the biggest problems with treating two people on one machine is that, while each person breathes differently, they had to be on the exact

The following ICU Room Contributor Wish List, shown in Figure 16, represents the three infectious pandemic surge room design features most requested by the users, experts, and design leaders interviewed while researching this article. These requests, along with a host of other recommendations and research data, informed the proposed ICU Room design.

Figure 16: ICU Room contributor wish list.

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4.3.4 Addressing ICU Room Wish List Items #1, #2, and #3

in current ICU design. The proposed patient room enlarges this station to include patient monitors and accommodation for PPE. In the isolation room, the ante room has been revised in a similar manner.

Diagram—Proposed ICU Room Adaptations: Figure 17 shows proposed ICU Room adaptations: nj Adding Windows: Visualization is key in every ICU setting and is mandated by code. In an infectious pandemic setting where the patient’s condition is more volatile and the progression of symptoms can even be unknown, it is even more crucial. Nurses interviewed report being able to tell when their patients stopped being able to breathe just by looking at them through windows. It is important to note that acute care patient rooms, which may flex as ICU during surge, also need windows in the doors.

nj Adding More Isolation Rooms: Isolation rooms are expensive to build and difficult to use for regular patients when no isolation patients are present (ante room use must be maintained. Bypassing the ante room by using the regular sliding doors, which is a quicker and more convenient way to enter the room if the patient is not infectious, will cause alarms to sound as the pressure differential between the room and the hallway is disturbed). Codes in most states mandate a minimum of one per unit. A surge situation, where numbers have not reached crisis levels, benefits from more isolation rooms.24 The proposed ICU design provides an optional two isolation rooms per unit.

nj Taking Monitors Out of the Rooms: Keeping staff out of the patient rooms as much as possible is emerging as a best practice during an infectious pandemic situation.

A charting station is often provided between two rooms

Figure 17: ICU Room adaptations.

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Figure 18: HVAC solutions for Airborne Infectious Isolation Rooms.24, 25

4.3.5 ICU Room HVAC Solutionsâ&#x20AC;&#x201D;Airborne Infectious Isolation (AII) Rooms

4.3.6 ICU Room Technology Solutions In addition to developments in clinical planning with regards to accommodating an infectious pandemic surge, new technologies are being developed every day to enhance and facilitate care. Some recent new ICU room technology solutions are outlined in Figure 19.

Negative pressure isolation patient rooms help contain the spread of pathogens in a unit by using the pressure differential to keep the infected air from spreading out of the isolation rooms. The ante room acts as an additional buffer. These rooms must exhaust directly to the outside and not recirculate the air into the main hospital HVAC system.25 See Figure 18.

Figure 19: Technology Solutions for ICU Patient Room.22

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4.4 The Hospital 4.4.1 Keeping the Hospital Healthy Flow: Although the ICU is the focus of this study, it is not an island. Understanding it means understanding how it fits into the larger hospital. Infectious pandemic surge planning must consider how staff, infectious patients, and supplies get in and get out. The safety of the patients and the staff in the unit, as well as the safety of everyone they come into contact with inside the hospital, is dependent on creating flows that minimize the spread of disease from the minute they enter through the front door of the hospital building.

During a pandemic, managing patient flow is especially important. Directing patients with different needs to different entrances can avoid overcrowding at the main entrance. For staffing and budgetary purposes, it is important to note that additional staff will be needed to screen and direct patients at the various entrances. That staff will be serving on the front line of the pandemic and will be in contact with many potentially infectious people. They will need additional PPE and appropriate workstations with barriers.

Operations: Keeping the hospital healthy means keeping the hospital viable. It is vital that we try and help these life-saving institutions stay as fully operational as possible during a Pandemic. Surgery is the lifeblood of the institution and clinicians and planners are studying how to keep this department fully functional in an infectious environment.

4.4.2 Case Study: Preventing the Spread—New York City, COVID-19 Minimize Patients in the Hospital: Solutions to reduce the number of patients at one time in the hospital and allow for social distancing include: nj Preregistration: Patients can fill out time-consuming paperwork at home and streamline the admitting process. nj Just-in-time: Patients must be seen at the times of their appointments—no waiting. nj Telemedicine/E-ICU: Allows patients to be seen from home and hospitals to communicate virtually.26

Figure 20: Hospital contributor wish list.

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Social Distancing: One of the biggest new challenges is accommodating social distancing. Hospital leadership interviewees state that at the height of the pandemic, when everything was “so scary and so uncertain,” it was almost easier than it is now. Once things started to return to the “new normal,” hospitals started seeing patients come back. They added elective surgeries back on the schedule. Suddenly, they were getting preCOVID volumes back in their spaces that were designed to accommodate patients at three feet apart vs. six feet apart.

Most elevators currently lack the proper air changes to minimize the spread of airborne infection. Retrofits are becoming available to address this issue. Refer to Figure 21 for more information.

4.4.3 The Hospital Contributor Wish List The following Hospital Contributor Wish List, shown in Figure 20, represents the three infectious pandemic surge hospital design features with regards to hospital design most requested by the users, experts, and design leaders interviewed while researching this article.

Patient Transport: regarding safe infectious patient transport are rapidly evolving. The ideal solution of providing completely separate circulation systems for infectious and non-infectious patients is currently prohibitive from both a spatial configuration and a budget perspective. Transporting infectious patients with proper PPE on, or with tenting if needed, through the usual hallways for short periods of time is currently deemed safe. A transport alert can be issued. Security can clear the hallways and the patient elevator. Staff should also wear full PPE during transport.

4.4.4 Addressing Hospital Wish List Item #1—Manage Infectious Patients Limiting the contact between infectious and noninfectious patients is vital to preventing hospitals from becoming super-spreaders during a pandemic.26 Figure 21 outlines methods for managing the circulation of infectious patients in a hospital setting.

Figure 21: Hospital circulation strategies to manage infectious patients.

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4.4.5 Addressing Hospital Wish List Item #2—Add Waiting Room Space

infectious and non-infectious patients within the Surgery Department by implementing isolation operating rooms with dedicated circulation and support is key to surviving the next wave and future pandemics to come. Figure 23 outlines some key features for the creation of an isolation operating room, including the desired flow of infectious within the overall surgical suite.

Managing the numbers of patients that come into the hospital is an effective way to maximize waiting room space without physically adding to the size of the room.

Figure 22 outlines methods for increasing waiting room capacity without adding extra square footage.

4.4.7 Case Study: Minimizing Supply—Chain Shortages— New York City, COVID-19

4.4.6 Addressing Hospital Wish List Item #3—Provide Isolation Operating Rooms

Logistics planners note that the supply chain difficulties experienced by the COVID-19 response have raised awareness regarding the critical importance of an effective supply chain. At minimum, reliable supplies of test-kits, equipment, pharmaceuticals, and PPE are essential to a continuous, successful response.

The operating room not only provides a vital function for the delivery of patient care, but it is also the main source of revenue for the hospital. It is crucial that the economic health of our hospitals is maintained so they can remain operational during infectious pandemics when we most need them. The scope of the economic fallout from shutting down surgical suites across the country that occurred during the 2020 March through June COVID-19 pandemic (to prevent the spread of the disease) has yet to be calculated but it is estimated to be devastating. Planning for the separation of

Consolidated Service Center: The current operational approach to supply chain logistics focuses on a justin-time model, where hospitals and health systems rely heavily on their distributor(s) for daily deliveries of primary medical and surgical supplies. A recent trend

Figure 22: Hospital waiting solutions to increase capacity.

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Figure 23: Hospital isolation operating room.27, 28

has created the same capability through a systemowned Consolidated Service Center (CSC). Instead of relying on outside sources that may not come through during an emergency, the hospital can draw from a proprietary off-site warehouse CSC for supplies.6 Figure 24 outlines various viable supply distribution strategies recommended by logistics consultants which can be used in tandem if desired.

Figure 24: Supply distribution strategies.

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Avoid Reactingâ&#x20AC;&#x201D;Plan the Response: Logistics planners must work with hospital teams to ensure there is not an overreaction to store significant inventory on site, causing a potential loss of revenue generating space.

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Figure 25: Hospital technology solutions.22

4.4.8 Hospital Technology Solutions

respond to an infectious pandemic and is reasonable (financially, operationally) for hospitals and systems to build (or adapt).

In addition to developments in clinical planning with regards to accommodating an infectious pandemic surge, new technologies are being developed every day to enhance and facilitate care. Figure 25 shows some new technologies that help manage infectious pandemics within hospitals.

5.2 Meeting the Need Meeting the overall need in a way that hospitals can afford and operate means leveraging the assets provided in a traditional ICU Unit design to allow the Unit to flex in times of infectious pandemic surge. This means that many of the components that make up the regular ICU will have dual-functions.

Technological devices are sometimes referred to as “toys.”

If not properly deployed, these expensive devices are toy-like. The key to proper deployment in a healthcare environment is understanding the workflow and the danger points within that workflow then identifying a technology that can reduce the risk or replace that part of the workflow with something else that is safe.

Some Examples of this strategy are: nj Flexing: Rooms that will not be used during a pandemic, (i.e., waiting rooms, patient education (multipurpose in California), consultation), will be used for needed pandemic functions such as: additional storage, work, and respite areas.

5.0 Conclusion 5.1 Defining the Need

nj Smoke Barriers: Will double as infection control barriers when flexing a unit for Isolation. Dedicated support instead of support shared between units is required in this configuration.

The research documented in this article began with the desire to identify a need. This led to conversations and interviews with front-line workers, designers, strategists, and various experts. It continued with synthesis, analysis, and formulation of design strategies.

nj Patient Room Headwalls and Booms: Will be situated to allow two patients in one room without impacting day-to-day workflow. Rather than doubling-up on

Simply put, the need identified through this effort is for an ICU that is designed to be prepared to

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Figure 26: Infectious pandemic surge ICU program.

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Figure 26: Infectious pandemic surge ICU program (Continued).

nj Departmental Gross Square Footage: Applying a standard ICU grossing factor of 1.6 to the overall net square footage of the Infectious Pandemic Surge ICU Program (8,465 SF) yields 13,544 Departmental Gross Square Footage—a modest increase of eight percent (1,064 DGSF) over the 12,480 DGSF Traditional Program.

these expensive services, additional outlets will be added to augment capacity. nj Work Areas: Will be configured for maximum efficiency, flexibility, and expandability and to keep staff safe in day-to-day as well as infectious pandemic surge circumstances.

nj DGSF Per Key Planning Unit: The Infectious Pandemic Surge ICU Program results in 1,129 DGSF per patient room vs. the Traditional Program at 1,040 DGSF. It is slightly above industry recommendations, which fall between 800 DGSF and 1,100 DGSF.

5.3 Space Program To ensure the highest standard of baseline critical care is incorporated, the following Infectious Pandemic Surge ICU Space Program was developed using a Traditional Best Practice ICU Space Program as its foundation

The Infectious Pandemic Surge ICU Program is represented side-by side with the Traditional Program in Figure 26, and the resulting additional square footage investment is calculated. Infectious Pandemic Surge Program elements that differ from the Traditional Program are highlighted in yellow.

The infectious pandemic surge elements outlined in this paper are incorporated into the program. Special consideration has been given to the grossing factors to prevent added square footage from making the solution unaffordable for healthcare systems.

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Peer Reviewers Ajla Aksamija University of Massachusetts Amherst/ Perkins&Will Becher Eli Neme Neme Design Studio Mahsa Farid Mohajer University of Massachusetts Amherst Diana Nicholas Drexel University Amanda Mewborn Navicent Health Suncica Milosevic University of Massachusetts Amherst Evan Schmidt Oregon State University

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Research Journal

2020 â&#x20AC;&#x2022; Volume 12.01

Authors 01

Doug Bergert Doug is an architect in the Minneapolis studio of Perkins&Will engaged in the planning and design of cultural, corporate, and education projects. A professor in practice at the University of Minnesota, his interest in wood cladding is tied to a larger pursuit to understand how buildings and their sites participate in natural, regional, and urban systems.

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Pratibha Chauhan Pratibha is a Planning and Strategy consultant in the Minneapolis studio of Perkins&Will who combines her background in architecture and research to find unique solutions to workplace challenges. Her passion for design, and rigor of research allows her to uncover data-driven insights that are critical to employee and organizational success.

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Daniel Lamoreaux Dr. Lamoreaux obtained his Ph.D. in School Psychology (Minor in Neuroscience and Architecture) from the University of Arizona. He is currently a nationally certified school psychologist in Tucson, Arizona where he leads his school district's threat assessment team and evaluates students' psychological, behavioral. and educational needs.

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Eve Edelstein

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Dr. Edelstein leads research-based design projects as scientific advisor to TUNED Lombardini 22, Italy, and CoFounder of Clinicians for Design, an international advisory group. Dr. Edelstein lectures and consults internationally on the impact of design on the brain, body and behavior.

Garrett Ferguson

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Garrett focuses on the wholescale implementation of sustainable design in architecture in the Dallas Studio. He believes that architects can change the world as they shape each project, ensuring the triple bottom line of sustainability is metâ&#x20AC;&#x201D;People, Planet, Profit.

Susan Ealer Susan is an architect and writer specializing in healthcare planning. She has more than 20 years of experience in programming, planning, and designing healthcare facilities.

She has written extensively about healthcare planning for marketing and technical publications in print and online. She is an Alfred P. Sloan Foundation Fellowship recipient and has produced award winning short-form documentaries about healthcare and social issues.

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This piece is printed on Mohawk sustainable paper which is manufactured entirely with Green-e certificate wind-generated electricity.

Through its â&#x20AC;&#x153;Green Initiativeâ&#x20AC;? Program, Phase 3 Media offers recycled and windpowered paper stocks, recycles all of its own post-production waste, emails all client invoices, and uses environmentally friendly, nontoxic cleaning supplies, additionally Phase 3 Media donates 5% of all sales from its recycled product lines to Trees Atlanta.

ISBN 978-1-7344881-0-4

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