Preparedness against disasters is a challenging issue for health systems. For example, the coronavirus disease 2019 (COVID-19) pandemic (as a mass causality unintentional biological accident) brought about many health challenges. Based on the past updates, during the pandemic, more than 554 million people were infected and more than 6 million people died. 1 –Reference Aminizadeh, Farrokhi and Ebadi 3 In this situation, policy-makers found that the preparedness of the health-care system was not acceptable. Challenges such as the lack of personal protective equipment, regulating quarantine and social distancing, making decisions in new emergency conditions, and most importantly the provision of hospital beds discovered deficiencies in health systems.Reference Garcia-Vicuña, Esparza and Mallor 4 –Reference Aminizadeh, Saberinia and Salahi 7
Different solutions are offered to create additional hospital capacity in response to mass causality disasters, however, 1 of the most practical methods is the establishment of hospital shelters. To be more detailed, the shelters are large-scale buildings/venues Author: Please provide highest academic degree for each author. Also, please confirm spelling and order of names. Thank you.
into hospitals used to treat patients and accommodate survivors. The role of the shelter hospital during and after a mass causality biological accident is to reduce the admission load of permanent hospitals by providing patients with medical care and life-saving conditions. On the other hand, by accepting mild-to-middle-symptom patients, shelter hospitals can reduce the likelihood of the spread of disease in society.Reference Bashawri, Garrity and Moodley 8 , Reference Fang, Pan and Li 9 The establishment of shelter hospitals in response to different disasters is a historical approach, through which public buildings such as schools, sports complexes, theaters, and large exhibition halls were converted into temporary hospitals. Large space and short-time conversion are 2 main characteristics of shelter hospitals.Reference Fang, Pan and Li 9 –Reference Wu, Xue and Legido-Quigley 11
Ansary et al. (2010) acknowledged that public buildings such as schools, religious facilities, and social centers can be used as shelters during disasters, although the vulnerability of these buildings should be evaluated in advance.Reference Ansary, Reya and Jahan 12 To exemplify, after the typhoid epidemic in Montreal, Canada (1910), and the influenza epidemic in Spain (1918), public buildings and large industrial centers were used as shelter hospitals to increase the number of hospital beds.Reference Adams 13 Also, a recent successful experience in the transformation of public venues into shelter hospitals was performed in response to the COVID-19 outbreak, especially in China. Several Fangcang hospitals provided surge capacity for patients with mild-to-moderate levels of disease. These temporary hospitals increased the number of hospital beds. The Fangcang hospitals had an undeniable role in the collapse of the epidemic in highly infected areas of China.Reference Garcia-Vicuña, Esparza and Mallor 4 , Reference Fang, Pan and Li 9 , Reference Chen, Chen and Chen 14 –Reference Naganathan, Meehan-Coussee and Pasichow 16
Several earlier publications evaluated alternative solutions to create additional hospital capacity in response to man-made and natural accidents as well as warsReference Eiseman and Chandler 17 –Reference Nagata, Arishima and Yamaguchi 20; however, information about intentional and unintentional biological accidents is very limited. Also, the nature of biological accidents is different from that of chemical, nuclear and radioactive ones.Reference Sharififar, Jahangiri and Zareiyan 21 , Reference Aminizadeh, Farrokhi and Ebadi 22 During biological accidents (intentional accidents like mass causality biological attacks and unintentional accidents like an epidemic), it is necessary to separate infected patients from society to reduce the spread of disease. In addition, providing surged hospital capacity and its related solutions is very important.Reference Artik, Varol and Cesur 23 –Reference Heidaranlu, Tavan and Aminizadeh 26 Therefore, the present study examines the main design criteria and necessary standards for transforming public buildings into temporary medical centers and shelter hospitals for the treatment and temporary accommodation of patients in response to mass causality biological accidents and epidemics.
Methods
The present study is a qualitative systematic review aimed to collect design criteria for temporary shelter hospitals in response to mass causality intentional and unintentional biological accidents. To find the main keywords, 10 related articles from high-ranking journals were studied, accompanied by pieces of advice from experts. The keywords were searched in databases including PubMed, Web of Science, and Scopus by a search strategy described in Table 1.
The inclusion criteria were the relevancy of the articles to the research question (design criteria for the transformation of public buildings to shelter hospitals in response to mass causality intentional and unintentional biological accidents), the types of included documents were original articles, reviews, letters to the editor, reports, practice, health policy and commentary published until November 2021. Also, the exclusion criteria are as follows:
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1. Articles dealing with chemical, nuclear, and radioactive accidents; wars; and natural disasters like floods and earthquakes.
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2. Articles focused on the design criteria of permanent hospitals.
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3. Articles whose full text was not accessible.
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4. Non-English language articles.
Table 1. Search strategy and keywords
After the systematic search, duplicates were removed. Then, the articles were evaluated based on the inclusion and exclusion criteria. In the initial screening, the title and abstract were assessed. The articles related to the research subject were fully evaluated in terms of content. The remaining articles were used to extract the design criteria for shelter hospitals in response to intentional and unintentional biological events. The PRISMA flowchart is presented in Figure 1. All the steps of the study, including selection, evaluation, and data extraction, were carried out by 2 researchers, separately. In each phase of data extraction, any controversy between the 2 researchers was discussed by a research team to reach a common idea, and then the next stage began.
Figure 1. PRISMA flowchart for included articles.
To extract the design criteria, a researcher-made checklist (as an Excel file) was used. The main extracted items were the title of the article, publication year, the type of biological accident or epidemic studied, the type of public building, the name of the shelter or temporary hospital, the capacity of the hospital, the number of admitted and recovered patients, and the design and establishment criteria of a shelter hospital in response to biologic disaster; because this study was a qualitative systematic review, the last step was the extraction of articles related to qualitative synthesis, in which the articles were read completely by the research team. Finally, the criteria for converting large public places into shelter hospitals in response to mass causality biological accidents were extracted.
Results
The total number of included articles was 1802, after removing the duplicates (n = 280) and initially screened articles (n = 1342), 180 related articles remained for content assessment. Twenty-nine articles were finally selected for extraction of the criteria (Figure 1).
Most of the final extracted articles were published by Asian researchers and studied temporary hospitals in China. Of the final articles (n = 29) entered into the study, 17 publications were carried out in Asia, 5 studies in North America, 4 studies in Europe, and 2 articles in Africa. Only 1 study was conducted with a global approach (Table 2). Almost all the articles described the design criteria for converting public centers into temporary hospitals in response to the epidemic of COVID-19 and Ebola. Most of the public buildings converted into shelter hospitals were sports stadiums.
Table 2. Characteristics of studied shelter hospitals
Table 3 describes the criteria to establish a shelter hospital in response to a biological disaster. The important factors were classified into 9 themes including location, layout, waste management, ventilation, information technology (IT) and communication, supplementation (drug and food), humanitarian supports, post-curing acts, and management measures. Each theme has some subthemes through which we defined the criteria.
Table 3. Themes and related criteria for conversion of large public venues to shelter hospitals
Discussion
The present study was a qualitative systematic review in which authors collected principal design criteria for converting large public venues such as theaters, stadiums, and large buildings into shelter hospitals in response to intentional and unintentional mass causality biological accidents such as pandemics and biological warfare. The design criteria were extracted in the form of themes, sub-themes, and criteria presented in Table 3.
Placement and Site Selection
Site selection for a temporary hospital or choosing a venue that can be converted into a shelter hospital is very important. One of the main criteria and primary requirements is the presence of stable resources of water and electricity in the large building. The preliminary resources should be adaptable for converting to a hospital and then returning to the primary condition. Additionally, escape routes are other important criteria for a temporary hospital. A shelter hospital without evacuation routes is not acceptable in the risk assessment.Reference Marinelli 31 , Reference Zhu, Wang and Xiao 32 , Reference Luo, Liu and Li 40 , Reference Tekin, Bayramoglu and Uzkeser 45 Also, the location of the shelter hospital should be accessible by the main roads for easy movement of patients and hospital personnel.Reference Chen and Zhang 41 Shelter hospitals are usually constructed for isolated patients with mild to middle stages of the disease. Normally, shelter hospitals do not have intensive care unit (ICU) wards and advanced laboratories. Therefore, the shelter hospitals should be placed in the vicinity of the referral hospital where the severe patients are transferred and there are advanced treatment facilities and laboratories. Accordingly, easy and quick access to a referral hospital is an important factor for the site of the shelter hospital.Reference Fang, Pan and Li 9 , Reference Naganathan, Meehan-Coussee and Pasichow 16 , Reference Shang, Xu and Cao 34 In addition, based on earlier studies, it is recommended that hospitals be located in the city center, however, they should be far away from at-risk buildings and places where susceptible populations gather, such as schools.Reference Fang, Pan and Li 9 , Reference Tekin, Bayramoglu and Uzkeser 45 , Reference You and Mao 46 , Reference Liu, Yin and Liu 48 In a study conducted by Moradian et al. (2018) focused on the site selection of temporary hospitals; criteria such as access to the airport, vicinity to permanent and referral hospitals, proximity to universities of medical sciences, distance from high-risk areas such as dense location, and the placement of the hospital in the central cities were suggested.Reference Moradian, Ardalan and Nejati 51
Structure and Layout
Various layouts have been suggested for the establishment of a hospital. However, in earlier studies, a 3-area and 2-pathway layout is highly recommended as the main layout of shelter hospitals in response to unintentional biological accidents. The physically separated areas are: (1) contaminated or red or hot area, (2) semi-contaminated or yellow or warm area, and (3) clean or green or cold area. The contaminated area is an area where patients are treated. The semi-contaminated area surrounds the contaminated area. The semi-contaminated area acts as a buffer zone between the contaminated and clean areas to reduce the possibility of infection transmission between patients and health staff. The clean area is very carefully controlled; it includes some free-contamination wards and sections such as the storage area for keeping raw materials, kitchen and pharmacy, resting rooms for hospital staff, and administrative parts. In addition, in shelter hospitals, there are 2 main routes, 1 is contaminated and the other is clean. The structure and shape of the hospital are designed in such a way that patients cannot enter the clean path.Reference Fang, Pan and Li 9 , Reference Chen, Zhang and Yang 10 , Reference Chen, Chen and Chen 14 –Reference Naganathan, Meehan-Coussee and Pasichow 16 , Reference Delgado, Quesada and García 27 –Reference Smolova and Smolova 30 , Reference Zhu, Wang and Xiao 32 –Reference Shang, Xu and Cao 34 , Reference Zhou, Gao and Li 37 –Reference Chen and Zhang 41
The space between contaminated and clean zones is filled with donning and doffing rooms. The donning and doffing rooms are places where the treatment staff must wear all the personal protective equipment (PPE) to enter the contaminated area and remove PPE completely when leaving the contaminated area.Reference Fang, Pan and Li 9 , Reference Chen, Zhang and Yang 10 , Reference Naganathan, Meehan-Coussee and Pasichow 16 , Reference Gordon, Ward and Yao 44 , Reference You and Mao 46 Also, there are strict camera-supervised controls for these rooms to ensure that all required steps of changing clothes and washing hands and faces are performed correctly.Reference You and Mao 46 , Reference Liu, Yin and Liu 48 In some studies, innovation has been designed by creating 2 channels, the first channel is directed to the contaminated zone, that is, the place where PPE is worn. Another channel is linked to the clean area where health staff should remove PPE and wash their hands. These channels are also moniored by cameras and are equipped with sound broadcasting and warning systems through which the inspectors can remind personnel of the correct wearing, removing, and washing acts. The difference between channels and rooms is the long length of the channels; for this reason, the longer the channels, the more time and the more accuracy for donning and doffing PPE.Reference Chen, Zhang and Yang 10 , Reference Chen, Chen and Chen 14
The triage and reception of shelter hospitals are located at the entrance.Reference Delgado, Quesada and García 27 However, in some plans, actual triage operations are performed in larger health-care centers (referral hospitals or temporary health-care sites) with an advanced IT system. In the plan, an IT-based connection is established between a referral hospital and the shelter hospital. Before the admission of the patient to the shelter hospital, his/her information has been sent to the shelter hospital using a well-coordinated IT system. In this model, IT staff are outside the shelter hospital and most of the administrative processes are performed out of the shelter hospital.Reference He, Xiao and Li 47
Concerning the placement of a disinfection channel to spray disinfectants, it is recommended that the disinfection channel be equipped with a lane of showers placed inside the hospital. The channel also can be located in the open space of the hospital.Reference Chen, Zhang and Yang 10 , Reference Dehghani and Ghomian 52 , Reference Chen, Chen and Chen 53 Of course, it should be considered that the frequent application of disinfectants during the COVID-19 epidemic posed health-care staff and patients with health risks.Reference Rafiee, Delgado-Saborit and Sly 54
An essential item in the structure of a shelter hospital is evacuation routes and corridors. Corridors should have enough space for delivering food and drug, commuting employees, as well as the exit and escape of patients and personnel. The width of the evacuation way should be 1 meter per 100 patients. Also, the width of the pathway between each zone should not be less than 4 meters.Reference Fang, Pan and Li 9 , Reference Smolova and Smolova 30 , Reference Zhu, Wang and Xiao 32 , Reference Luo, Liu and Li 40 , Reference Tekin, Bayramoglu and Uzkeser 45 , Reference You and Mao 46 To facilitate the movement of health-care staff and patients, fixing signs and labeling are very important. All wards and pathways should be marked with different colors. Also, the pathways for patients and staff should be recognizable.Reference Shu, Ji and Chen 28 Infected hazardous waste, collected in the contaminated area, should be transferred to the incineration area through a specific pathway at the end of the contaminated.Reference Zhang, Shi and Cao 35 , Reference You and Mao 46 To reduce the contact between the hospital staff and the patients, walls with 2-sided cabinets can be used. Health-care staff can put food and drug on 1 side of the cabinet and then patients bring the material from the other side of the cabinet without any face-to-face connection.Reference Naganathan, Meehan-Coussee and Pasichow 16 Also, in each section, a sufficient number of basic life facilities such as showers and toilet seats should be installed. For example, 1 toilet seat should be placed for every 10 women and a seat for every 20 men.Reference Fang, Pan and Li 9 Due to religious issues in Islamic countries, the separation of women’s wards from those of men is suggested.Reference Dehghani and Ghomian 52
In the previous studies, the space of room allocated for each patient was differently suggested. For example, the dimensions of 2 × 2 metersReference Shu, Ji and Chen 28 or 3 × 3 metersReference Delgado, Quesada and García 27 and a 1.2 meters distance between bedsReference Yuan, Qiu and Wang 39 were recommended for each room. Regarding the methods of separating the beds, it was generally recommended that the rooms be partitioned with 3 or 4 walls. In the 3-wall model, a curtain is used at the entrance. But in all these isolation methods, the main point was sufficient ventilation for the patients.Reference Fang, Pan and Li 9 , Reference Gordon, Ward and Yao 44
Outdoor Space
The outdoor space of a public venue has several applications. First, the placement of parking is very essential, although most public places already have enough space for parking. In some studies, it has been recommended to install a room or space for the relatives of patients.Reference Delgado, Quesada and García 27 Another outdoor part is a recreational area where patients can take a walk or do sports such as yoga. One of the main differences between Fangcang hospitals compared with previous models of shelter hospitals was the recreational facilities. Because the patients had to stay in the hospital for a long time, facilities for entertainment activities were provided by a big digital library including a collection of books, video clips, and other electronic media. The electronic resources had mostly motivational and psychological content.Reference Chen, Zhang and Yang 10 , Reference Jie, Shu and Chen 15 , Reference Zhang, Shi and Cao 35 The outdoor space of the public venue was also assigned to the waste incinerator, which was connected to the contaminated zone through the waste transfer pathway.Reference Yuan, Qiu and Wang 39 , Reference Luo, Liu and Li 40 In addition, because infected wastewater should not be directly discharged into municipal wastewater sewage, the hospital should be equipped with a small-scale wastewater treatment plant for the pretreatment and disinfection of wastewater before discharging wastewater into municipal sewage.Reference Fang, Pan and Li 9 , Reference Luo, Liu and Li 40
Ventilation
One of the main problems with the transformation of public places into shelter hospitals is the adaptation of the ventilation system. In most cases, the ventilation system should be redesigned.Reference Fang, Pan and Li 9 , Reference Marinelli 31 , Reference Shang, Xu and Cao 34 Two general principles recommended for changing ventilation systems in shelter hospitals are the provision of negative pressure in the contaminated zone and the negative pressure gradient from the contaminated zone to the clean zone in a way that the contaminated zone has the most negative pressure.Reference Fang, Pan and Li 9 , Reference Naganathan, Meehan-Coussee and Pasichow 16 , Reference Smolova and Smolova 30 , Reference Gordon, Ward and Yao 44 At the beginning of the project, if negative ventilation is not available in the contaminated zone, providing a positive pressure in the donning and doffing rooms, the negative pressure will be created in the contaminated area as a temporary solution.Reference Fang, Pan and Li 9 An innovation used in a shelter hospital in the United States was the application of 2 air transmission channels for the entire hospital. For each room, there were 2 air vents; a blower vent above the entrance of the room, which brought clean air (from a clean air channel) into the room, and a suction vent connected to the second channel, which was installed above the patient’s bed and removed air from the room.Reference Gordon, Ward and Yao 44 The ventilation system is connected to high-efficiency filters that minimize the risk of airborne contamination. The filters are disinfected by ultraviolet (UV) disinfection, which reduces the risk of contamination for the workers who change the filters.Reference Gordon, Ward and Yao 44 Furthermore, in another study, displacement ventilation was suggested as an alternative to improve the ventilation system of shelter hospitals. All the rooms had 2 types of inlets: (1) low-level air intake located near the surface, (2) high-level extract placed in the ceiling. It provides negative pressure. The model works as either mechanical or natural ventilation (50). Based on the standards for ventilation in hospitals, replacement of fresh air should be performed 2 to 3 times per day.Reference Wang, Wang and Shen 33 If a shelter hospital has an ICU, ICU rooms should be occupied by an independent negative pressure ventilation system.Reference Levy, Zucco and Ehrlichman 42
Along with ventilation, another elemental factor is temperature. In cold climates or during cold seasons, excessive ventilation may increase the need for heating inside the hospital. In this case, it is better to use electric blankets for patients, which increases energy consumption. Also, due to the large space of shelter hospitals, air ventilation may not be well-performed in some areas. For this problem, it is recommended to use air purifiers in unventilated areas to reduce virus-laden aerosols. The filters applied in the air purifiers should be disposed of as hazardous medical waste.Reference Chen and Zhao 49
IT and Communication
The role of the IT unit is very important in the case of shelter hospitals. For example, during the COVID-19 pandemic, many tasks were IT-centered performed. In some projects, the IT unit was in the referral hospital close to the shelter hospital; and the reception, monitoring preparing documents for the transfer of patients, and providing laboratory tests were implemented by the IT unit. The better the IT unit is operated, the less contact between patients and the treatment staff will be. However, it should be considered that complete reliance on the technology-based system may have some problems. For example, following a biological incident, a cyber-attack may also happen, if there is no ability to quickly shift from an electronic system to a manual one, many problems may arise.Reference You and Mao 46 –Reference Liu, Yin and Liu 48
Food and Drug Delivery
The valuable experience that Chinese scientists reached out in the fight against Ebola helped them to control the COVID-19 pandemic. For example, there were many similarities between the shelter hospital established in Samuel Kanyon Doe Sports Stadium by Chinese scientists in response to the Ebola epidemic in Liberia and the Fangcang shelter hospital which was designed for hospitalization and isolation of COVID-19 patients in China. In both models of the shelter hospital, the IT and communication unit had a substantial role in drug and food delivery. Every day, the amount and types of required food and drug were ordered to the hospital catering and central pharmacy, respectively, using an IT system.Reference You and Mao 46 –Reference Liu, Yin and Liu 48
When it comes to the design of the pharmacy, it has 2 rooms: dressing and drug storage rooms. The dressing room is the place to wear PPE for the pharmacy staff who must distribute the medicines in the hot zone. The staff wears PPE based on the place where they must deliver the medicine.Reference Chen and Zhang 41
Management Measures
Because the use of a large public place as a hospital is a sensitive matter, before starting the project, a detailed risk assessment must be performed for the proposed places. The results of the risk assessment must be considered by the health providers, architects, and other involved specialists. After choosing a place, effective communication with the neighborhood council or influential persons in the area could be useful in speeding up the project.Reference Tadavarthy, Finnegan and Bernatowicz 29 During an epidemic, especially considering the experience gained from the COVID-19 pandemic, it is very important to provide PPE for the medical staff. In shelter hospitals, the importance of using PPE is much higher due to the risk of cross-contamination in these hospitals.Reference Chen and Zhang 41 Another important management measure is training health-care staff using updated guidelines. During epidemics or mass casualties in biological accidents, many volunteers cooperate with the medical staff in different medical centers. The training of these people can lead to the improvement of services.Reference Chen, Zhang and Yang 10 , Reference You and Mao 46
Important Consideration for Design of Shelter Hospitals
In addition to supplementation of basic needs such as water and electricity, it is essential to provide alternative sources for emergencies. An essential factor for choosing a building is the space, the amount of minimum space varies in different regions; generally, the shelter hospital should provide space of 600 to 1000 beds, although in some cases, depending on the type of building, undertaking incident or epidemic, and population of the city, the number of beds may vary.Reference Fang, Pan and Li 9 , Reference Chen, Chen and Chen 14 , Reference Naganathan, Meehan-Coussee and Pasichow 16 , Reference Marinelli 31 , Reference Jones, Siddiqui and Callahan 43 Also, it should be considered by policy-makers, as well as architects of public places, to have an active plan for all the large public buildings. The action plan is a map showing how a large building can be converted into a shelter hospital or health-care facility. The plan should be provided at the end of the building construction.Reference Fang, Pan and Li 9 Another important issue is related to the post isolation care of recovered patients in some places like hotels. Based on the nature of biological accidents or pandemics, it may be necessary to quarantine the patients after healing, because some biological agents may be active for a long time.Reference Chen, Zhang and Yang 10
Conclusions
In mass causality biological accidents or epidemics, creating additional capacity to hospitalize and isolate patients is very important, because it can reduce the spread of disease in the community. A successfully applied way to create surge capacity is the transformation of large public buildings or venues into shelter hospitals. They can be constructed easily and quickly. However, a lot of criteria and considerations should be taken into account for the establishment of shelter hospitals to isolate patients and prevent cross-contamination among health-care staff. Previous studies have indicated many criteria and innovations to transform public places into temporary hospitals, which have been systematically collected in this study. Having a suitable space, redesigning the ventilation system, and providing basic resources such as water, electricity, and oxygen are among the main measures for the conversion of public places into shelter hospitals. Although design criteria may vary in different regions due to cultural, social, and economic differences, the results of the present study can be used as a reference through which health policy-makers could correctly respond to biological accidents and pandemics.
Competing interest
None declared.
