In 2004, as part of nationally coordinated antiterrorism efforts, Nebraska Medicine brought online a first-of-its-kind unit for the safe treatment of deadly infectious diseases. Early involvement of frontline staff with the design team of Leo A Daly was crucial to creating a unit that met the complex safety, operational, and psychological needs of clinicians working in this challenging environment.

Now, in the wake of the 2014 Ebola outbreak and the role that Nebraska Medicine played in treating its victims, lessons learned by that same staff are helping guide the design of the next generation of biocontainment patient care units.

A first
With funding from federal bioterrorism dollars allocated to Nebraska in the wake of the Sept. 11 attacks, Nebraska Medicine and the Nebraska Health and Human Services System collaborated to create a 10-bed unit equipped to care for people exposed to highly contagious and dangerous diseases.

After the concept of a biocontainment unit was developed, an extensive planning stage took place, led by three key Nebraska stakeholders in the public health plan: Dr. Philip Smith, an infectious disease specialist; Dr. Richard Raymond, Nebraska chief medical officer; and nurse Patricia Lenaghan, chair of the Omaha Metropolitan Medical Response System.

From the initial planning of the Nebraska Medicine biocontainment unit, collaboration between design and clinical staff brought questions of safety, operational procedures, and staffing—driving Leo A Daly and Nebraska Medical Center to engage and include nurses and other hospital professionals in a transparent and interactive planning and design process.

Staff nurses participated in all key initial design decisions as members of interprofessional teams. Leaders from pharmacy, radiology, electrocardiogram, dietary, environmental services, and other departments took part in a two-step process to weigh in on the unit’s design and develop processes for how they would interact with the unit. Procedures for moving equipment in and out of the unit, donning and doffing personal protective equipment (PPE), and stocking the unit had to be developed.

Operations input from nursing staff influenced the unit’s throughput, essential spaces, and equipment, leading to practice innovations and a safe working environment.

As for the structure itself, the unit was retrofitted into an L-shaped wing of an existing hospital tower. Placing it on the top floor allowed engineers to plan the unit’s unique engineering system without disruption of other patient care areas. Significant renovations were made to seal the wing off from the rest of the hospital. A dedicated air-handling system processes all air entering and exiting the unit, flowing in through HEPA filters, following a clean-to-dirty path within the rooms, and terminating with redundant fans and HEPA filters on the roof. Rooms are kept at negative pressure and monitored with a pressure alarm.

An unused unit that previously housed a pediatric laminar flow unit was selected as the site because it was relatively isolated and had a separate air handling system. The Nebraska Department of Health and Human Services also required 10 ICU-capable beds, which could be accommodated in the 4,000-square-foot space. Its five rooms ranged from 214-228 square feet and were large enough for two beds with medical gases. Later, the rooms were converted to single-occupancy.

After working with nursing staff to audit the proposed operational procedures of the unit, the design team created a layout using clean-to-dirty principles in order to limit the potential for contamination. For example, staff enter the unit through a dedicated entrance equipped with pass-through lockers and scrubs. After their shift, they can “shower out” into a changing area and access their personal items through doors on the opposite side of the lockers, which is considered “clean.”

Patients and materials enter through a secured air lock, keeping the arrival area clean. Soiled items exiting the unit, including used PPE, biological waste, and bedding, do so via an autoclave that purifies them with high-pressure steam. A chemical dunk tank was installed to chemically decontaminate the exterior of lab-sample containers and X-ray cassettes that are needed outside the unit.

Amenities for staff and patient comfort include a nutrition station, large windows offering natural light, and video phones. Patients in biocontainment for extended periods are susceptible to “ICU psychosis,” a disorder in which patients in an ICU environment experience a cluster of serious psychotic symptoms, often related to sensory deprivation, sleep disturbance, continuance hospital light levels, stress of critical illness, infectious process, dehydration, metabolic disturbances, and continuous monitoring.

This can be prevented by creating a calm and restful environment that supports family interaction as much as possible, both challenges in the biocontainment environment. In this case, a video phone served as a lifeline, connecting the patients to family and friends, while giving consulting physicians an opportunity to see and communicate with the patient without entering the unit.

Overall, the inclusion of staff in all of these decisions resulted in a unit that was backed by the confidence of those who would use it.

Lessons learned
The Ebola outbreak in 2014 became a worldwide concern, with more than 27,000 cases and 11,000 deaths documented. Eventually, the disease found its way to the United States, and three U.S. citizens, infected while working in Liberia and Sierra Leone, were transported to Nebraska by the U.S. Department of State. The first two patients required 11-14 days of treatment and were eventually released. The third patient was critically ill on transfer and eventually succumbed to the illness after three days.

The unit’s activation provided a number of important lessons in the safe treatment of dangerous diseases, as well as an opportunity for the design team to revisit the 2004 design and gather insights from its real-world operation that could be applied to future projects. To that end, Leo A Daly met with facility leaders just days after the first Ebola patient was discharged disease-free in late September 2014.

Staff reported that the unit performed well in its primary purpose of safely treating its patients. However, in the course of use, some tweaks were made.

Foremost was the installation of a lab within the unit. Frequent and timely laboratory tests were needed to make rapid treatment decisions. Sending samples to the hospital lab took up valuable time because of the required chemical decontamination of the holding bag via the dunk tank, so one of the five patient rooms was repurposed into a point-of-care lab, yielding a significant reduction in turnaround time.

The large volume of waste produced in the treatment of Ebola proved a logistical challenge for staff, as well. A single patient generated enough waste every day to keep the autoclave occupied for 12 hours. Even with round-the-clock autoclaving, this would limit the unit to two patients maximum—an eye-opening insight for future design. It also introduced a storage challenge, requiring an unused patient room to be converted into “dirty” storage, with another patient room transformed into a second “clean” storage space.

The waste-handling protocol for the unit required PPE-clad staff to double-bag soiled materials and place them in dirty storage until they could be autoclaved. Transferring soiled items from the patient room to the storage area, and then again to the autoclave room, required staff to wal
k through a “warm” zone (an area that requires caution because of the potential for contamination) while carrying bags of hazardous material. Although not ideal, the procedures developed by the staff at Nebraska Medicine were effective in mitigating this situation. However, future biocontainment units could be improved by designing a throughput that avoids the transfer of soiled material through those areas and creates a separate path for trash, linens, and autoclave items. 

It was realized that nurses, specifically, play a multifaceted role in this unique environment, too. Maintenance staff aren’t permitted to enter the unit during activation, so nurses must be jacks-of-all-trades, fixing clogged toilets, replacing light bulbs, or providing general maintenance, in addition to cleaning. For example, when a minor repair was required during the unit’s operation, the nursing staff requested an in-unit maintenance kit and the associated training to handle simple fixes.

The nightly cleaning regimen of the unit involved the use of a bleach solution. Although the unit was designed with sheet-vinyl flooring rated to withstand bleach, the welded seams took some chemical damage that required repair between patients.

The mental health and body strength of the patient were also areas of concern. In response, Nebraska Medicine added an exercise bike and chess board to the room. Staff played chess with the patients to keep up their morale and mental acuity, and the exercise bike was used in later stages of treatment when the patient was capable of moving around but still confined to the unit.

Finally, during the Ebola outbreak, media interest in the unit was high, leading administrators to install a security guard at the front of the unit. This suggests that future biocontainment units should include space for security personnel.

The next generation
The insights gained during the outbreak have significant implications for healthcare designers moving forward. Right now, Leo A Daly is designing a biocontainment unit in a major U.S. city using guiding principles informed by this experience and developed in collaboration with stakeholders.

The schematic design for this project reflects lessons learned from the experience in Nebraska. It responds to operational challenges experienced during the treatment of Ebola patients, including the need for a point-of-care lab, a stricter delineation between “hot” and “cold” zones, and the need for an extra autoclave as well as extra storage in the hot zone.

Flow between clean and dirty spaces is upheld through the observance of cold and hot zones, with all critical functions related to patient care and waste processing located in the hot zone. Staff enters the hot zone through an anteroom off the cold corridor, donning PPE before entering the patient room. From here, staff has access to the patient room, waste-handling and holding room, lab, and autoclave without passing back into the cold zone. All contaminated waste is either autoclaved or chemically decontaminated prior to leaving the unit.

Redundant autoclaves are provided on opposite ends of the unit in case of equipment failure and to allow for surge capacity, allowing one to function if the other breaks down. Ample waste storage is provided in the hot zone pre-autoclave, and in the cold zone post-autoclave. Pass-through showers allow staff members to shower out back into the cold corridor after their shift in the patient room.

Extra storage is provided in the cold zone for tools and cleaning equipment in case a repair is needed.

Because patient family and significant others are key to recovery and need the opportunity to participate in care without entering the unit, a family waiting area is provided. Space is dedicated to security personnel, too, limiting the opportunity for the public to access the unit.

Overall, the success of the Nebraska unit reinforces the importance of including clinical staff in the design and development of the unit to achieve the buy-in necessary for effective operation. Furthermore, by circling back with the unit’s staff after activation of the unit, the design team gathered valuable insights that can build upon on the ideas presented in the initial unit and increase the body of knowledge available to the design community.

The success of these units is the result of the dedication of clinical staff who are rigorously trained to work in even the most difficult environments, and a design team’s role in the process is to support their efforts by providing an environment where the only way to perform any task is both the most efficient and safest.


Robert D. Counter, AIA, is director of healthcare for Leo A Daly Los Angeles. He can be reached at Patricia A. Lenaghan, RN, MSN, NE-BC, FAAN, is senior healthcare clinical and operations analyst for Leo A Daly. She can be reached at