Several decades of managed care and evolving technology have dramatically reduced the number of inpatient beds in U.S. hospitals. The result is an inadequate capacity to provide medical care to large numbers of patients should a man-made or natural disaster occur.

On December 1, 2004, a group of energetic thinkers met at Texas A&M University in College Station, Texas, for the Medical Readiness Conference, organized by the Texas A&M University System Health Science Center and College of Architecture, to discuss a series of innovative concepts related to the medical aspects of homeland security. The group included United States Surgeon General Richard H. Carmona, MD, MPH, FACS.

A highlight was the presentation of design projects by 17 two-person teams of Texas A&M architecture students for model “SURGE” hospitals, designed to respond to surges in numbers of patients in the event of a natural or man-made disaster. Such disasters could cause existing hospitals to become overwhelmed, inoperative, or inaccessible. A network of predesignated, self-sustaining SURGE hospitals would provide an alternative to our nation's existing healthcare system during emergencies.

We had charged the 34 students in October 2004 to produce self-sustainable, cost-effective designs for buildings that could be used as temporary hospitals during disasters and for other purposes between crises—i.e., “dual-use” facilities. We instructed the students that the designs should allow the integration of mobile-unit technology with the buildings.

These mobile medical units are commercially available and come in a variety of configurations. They have been used for more than nine years in the United States and have been inspected and licensed in nine states so far. Hospital inspections by the Joint Commission have found them to be fully compliant with all statutes. These units could provide surgical, ICU, dialysis, lab and pharmacy, x-ray, eye care, women's healthcare, and dental services. They would have basic equipment and supplies aboard. The mobile units should be able to rapidly interface with the facility used as a SURGE hospital and should be appropriate for medical response to all possible threats and hazards facing the community.

This project is the result of a cooperative and interdisciplinary effort between the Departments of Architecture, Construction Science, Landscape Architecture, and Urban Regional Planning, as well as the Center for Health Systems and Design, the Hazard Reduction and Recovery Center, and the CRS Center—all entities within the College of Architecture. The Texas A&M University System Health Science Center's physicians agreed to act as “clients” as the students and faculty explored the design of SURGE hospitals.

Basic Scenarios Guiding the Designs

A number of events could necessitate the rapid activation of SURGE hospitals, including natural disasters such as floods, hurricanes, fires, earthquakes, epidemics, and chemical spills or acts of terrorism or warfare—e.g., sabotage, bombing, and biological, chemical, or nuclear attacks.

The students were encouraged to come up with a broad series of possible disaster scenarios and innovative responses to those events. Some of the situations they projected involved access, triage, and decontamination for large numbers of casualties. Storage and distribution of food, potable water, medicines, medical supplies, clothing, beds, blankets, and shelters were addressed in the designs, as was the critical need for emergency generators and emergency power.

The equipment and supplies could be placed in storage areas provided in separate storage buildings on-site or within the facility. Space between floors could be used, as well as large storage areas on each floor.

The students' designs for the SURGE hospitals included open areas where tent structures could be placed for housing mass casualties, with adequate space for helicopters to land and take off. Security issues that would require crowd and panic management were also discussed, as well as how to plan for the safe and efficient flow of numerous vehicles, including ambulances, cars, buses, and trucks transporting large numbers of casualties to the SURGE hospital (figure 1). For example, wreckers would need to be available on-site to immediately tow vehicles out of the way to accommodate the surges in vehicles and patients. These flow patterns are critical in the initial design because a SURGE hospital's traffic would flow very differently in a mass-casualty situation than traffic moves at a permanent healthcare facility in peacetime.

Range and Scope of the Projects

The project proposals ranged from adapting the Washington (D.C.) Convention Center and an adjoining hotel to serve as a SURGE hospital that could accommodate thousands of casualties, to converting a small motel and an adjoining clinic in Schulenburg, Texas, to accommodate surges of patients and casualties from the urban areas of Houston or San Antonio. Another solution proposed adapting an arena in Laredo, Texas. Each of the 17 projects had unique and original design ideas.

The proposed structures ran the gamut from hotels to community centers to schools that could be quickly converted to SURGE hospitals in times of disaster. Such dual-use facilities could earn their keep by functioning as community assets during normal operations. These buildings would be identified to the public with a sign bearing a SURGE hospital logo (figure 2). This sign would serve the same purpose as the fallout shelter signs used in schools and other buildings during the Cold War era.

The students addressed the cost-efficiency of the surge facilities via the dual-use concept. One issue discussed was what would motivate a potential hotel owner, for example, to take on the added expense of storage space for a SURGE hospital. Some possibilities could be tax incentives or tax waivers over the life of the building. Plans for modular expansion of the facilities—by only using what is needed when it is needed, based on continuous assessment of that need—would help to control costs. It is possible that the wider hallways and elevators needed for moving patients, the backup power systems, and extra security measures for the buildings could be paid for by a state or federal tax initiative.

This nighttime aerial view, rendered by Texas A&M College of Architecture students Andrew Burleson and Joshua Cogburn, shows how traffic flow—both of vehicles and patients—could be handled in a disaster situation, including a power outage

Project Details

Six of the projects focused on converting a hotel to a SURGE hospital, a concept that takes advantage of the many small rooms that could be used as patient rooms and the lodging function of a hotel layout. Some special considerations would be where to locate a morgue, how to provide oxygen, and where decontamination and triage areas would be located. Hotels designed for dual use would provide a service to the community during ordinary use, and the open floor plans of their conference space would be easy to quickly convert to disaster-response use. Hotels also have trained food service staffs, who could be encouraged to support the needs of victims and emergency workers in a disaster.

These designs are compatible with the modular use of mobile units—stocked with medical equipment and supplies and with lab and imaging equipment on board—and with the Strategic National Stockpile (http://www.bt.cdc.gov/stockpile), a portable pharmaceutical and vaccine supply system directed by the Centers for Disease Control and Prevention. The dual-use hotel designs include high-volume entry and exit features; traffic management for emergency, supply, and casualty-transport vehicles; and rapid access to nearby freeways, trains, and airports.

Created by Texas A&M College of Architecture students Allison Prehn, Lindsay Widener, and Lindsay Hieb, this logo could be used to identify SURGE hospitals to the public

Two design projects proposed using a single-story school building as a SURGE hospital. Schools have the attractive feature of wide hallways, allowing two-way gurney or stretcher traffic, and a single-story building would lack the stairs and elevators that could become bottlenecks during high-volume events. Under most circumstances, school activities could be cancelled or diverted so that the facility could be converted to a SURGE hospital, making the space quickly (in a matter of hours) available. A network of parents and teachers would need to be in place ahead of time to make sure students were picked up promptly.

Schools' delivery and drop-off points are already designed to support “surges” in students at the beginning and end of the school day. These would be equally useful in handling traffic flow in a disaster situation. Food services could be set up quickly or continued in the school cafeteria for casualties and emergency workers.

Six design projects proposed using a single-story convention or community center building as a SURGE hospital. These large, open facilities are easily converted to housing and hospital functions in times of disaster—even more so with the design foresight shown in our students' projects. For example, in some designs, cots would be stored under a gymnasium floor. The gym floor would be dismantled and the cot floor raised (like an orchestra floor) in its place. The flow of emergency and supply vehicles could be optimized while still serving the best interests of the routine use of the structure. These buildings could shelter hundreds or even thousands of people at once. Food services designed to accommodate large groups of people are often already available in these facilities—another attractive dual-use feature.

Two projects proposed using an existing outpatient clinic and its surrounding buildings and parking facilities for conversion to a SURGE hospital. Clinics have the advantage of already being designed for patient care, with adequate waiting areas and space for patient flow. Using nearby buildings for overflow and inpatient facilities, such as in the case of the clinic with the adjoining motel described earlier, would combine the many advantages of a daily-use healthcare facility with the attractive features of its surrounding buildings.

The variety and ingenuity of these design projects show the diversity of solutions that are available to America's communities, large and small, to plan for medical care in natural and man-made disasters.

In some communities, new construction of buildings, using the basic principles of dual-use adaptability described earlier, will be necessary. In others, an addition to an existing structure will be the best plan. Some will be able to adapt buildings already in use, with minimal renovation to suit their needs for the threats they face. The need for SURGE hospitals also might require building-code variances, e.g., wider hallways or the exclusion of stairs and elevators. The students' projects demonstrate each of these solutions, with a variety of dual-use approaches, and show how SURGE hospitals could be both self-sustaining and cost-effective.

Surgeon General's Comments

After engaging in enlightening discussions with the architecture students and inspecting their project boards for their SURGE hospital designs, Dr. Carmona had high praise for the innovations and clever insights the students showed in their projects.

The innovative concepts discussed at the Medical Readiness Conference could help prepare America for the many threats we face today. However, will we ever be fully prepared for any disaster or act of terrorism? “Not in my lifetime,” Dr. Carmona said. But we are making great strides, and these improvements will likely save many lives. Dr. Carmona noted, “Those who are working in disaster response and homeland security can do a better job of telling Americans and their leaders about the many remarkable solutions that have come from the medical community in recent years. While we can't rest on our successes, we can sincerely reassure our patients and political leaders that much has been done.”

Conclusions

The United States of America needs an alternative network of SURGE hospitals in order to be prepared to handle natural and man-made disasters. The 17 research and design projects undertaken by students and faculty at Texas A&M University's College of Architecture greatly helped to stimulate thinking about the what, why, and how of designing SURGE hospitals. We hope we will never need any of them, but we must be prepared. HD

George J. Mann, AIA, is The Ronald L. Skaggs Endowed Professor of Health Facilities Design, College of Architecture, Texas A&M University; President of GUPHA (Global University Programs in Healthcare Architecture); and Founder and Chairman of the RPD (Resource Planning and Development) Group, College Station, Texas. Contact him at 979.845.7856 or

gmann@archone@tamu.edu.

Paul K. Carlton, Jr., MD, FACS (Lt. Gen. USAF Ret.), who hosted the Medical Readiness Conference detailed in this article, is the Director of the Texas A&M University System Health Science Center's Office of Homeland Security and former Surgeon General of the United States Air Force. Contact him at 979.458.7246 or

carlton@tamhsc.edu.

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Editor's note: At the time this article was written, Hurricanes Katrina and Rita had not yet struck the Gulf Coast.