How architecture in long-term care homes can help prevent infection and improve quality of life

A doctor who specializes in designing spaces for geriatric patients says there is "a moral imperative" to ensure seniors' residences, including long-term care homes, are designed properly to help prevent the spread of infectious diseases like COVID-19.

In Canada, the majority of COVID-19 deaths happened in long-term care homes. 

A CBC Marketplace analysis of COVID-19 deaths in nursing homes in Ontario points to older buildings with shared accommodations — such as four-bed wards — as one possible cause.

Dr. Diana Anderson, a physician and architect from Montreal, is currently the geriatric medicine fellow at the University of California's San Francisco Medical Center. She also calls herself "The Dochitect."

Here's part of her conversation with Checkup host Duncan McCue.

What are some of the common design elements in long term care homes, in seniors homes, that contribute to the spread of a virus like COVID-19?

Although long-term care in nursing homes are not strangers to infectious outbreaks, it's something that we deal with quite frequently in geriatric medicine.

As you can expect, in these types of long term care settings, older residents are living in close quarters. They often have high levels of chronic illness, and all of this leads to greater infectious outbreaks and possibly mortality.

I think some of the environmental issues that make nursing homes prone to infection from a design perspective are: Number and density of residents — people are talking about this recently; the numbers of staff and visitors who access these buildings; and staff movement, of course, between multiple resident rooms; and then some of these high-traffic communal areas like dining rooms or living areas.

Are there building changes, like literally architectural changes, that long-term care homes should be considering when it comes to the spread of infectious diseases?

So I think there definitely should be…. For instance, we know that in hospitals, if you move to a single-room model for patients, we get a sustained decrease in the rate of new infections. There's a recent medical journal article that came out that proved that.

We also know that the incidence rate of falls is lower among patients who have better access to a window in a shared room versus being in the far side of the room without a window.

Personally, I think architects and health care architects specifically, we have a moral imperative to ensure that the buildings we're designing are not causing harm.

If we know that a double- or even single-patient room can impact the rate of falls, patient satisfaction and quality of life, family involvement [and] infection, then I think we have a duty to update our building codes and even force-retrofit, instead of grandfathering in buildings from the 1970s that feature these types of spaces.

Are there any examples in Canada that are getting it right, architecturally?

I think what we're seeing in terms of research and certain built environments are smaller settings: long-term care homes that are looking at smaller households, or what we call clustered residential settings, typically less than 10 residents that have a dedicated staff. That improves quality of life, and they also benefit infection control.

Sink placements are also very important in some of these facilities. McGill had a 2016 study that came out that said: For every additional distance of one metre that I as a provider have to walk to the sink to wash my hands, the likelihood that I'll wash them goes down. 

So [we're] thinking about how can we put infection control measures in place, but not make it like a hospital, right? Because nursing homes are not hospitals; they're sort of in between.

I'm sure there are people listening saying that this all makes such sense, Dr. Anderson. But how much is it going to cost, if we're talking about making changes to bricks and mortar?

It might cost more initially, but the return on investment in terms of not only savings financially but also quality of life is something I don't think you can even put a price tag on.

What worries me about COVID-19 and nursing homes in Canada, and even here in the U.S., is that I worry architects and those running these facilities and policymakers will be very reactive, in terms of now thinking about: "How do we design for infection control?"

But I think that is too narrowly focused. What we need to step back and do is really be proactive instead of reactive and say: "How can we design facilities for older adults to maximize collaboration, social interaction, mobility, and basically foster quality of life?"

I think if we do that, we'll yield pandemic preparedness and an overall resilience of buildings if we go that direction rather than just designing for infection control.

Are there any examples that stand out for you and in countries that have mandated some changes in design to the way that where our seniors reside?

In Europe, we're seeing the "dementia village," which actually we have one now in Canada on the West Coast. And these types of facilities are more of a village-like setting that don't close people in, but really promote purposeful movement.

We know that areas of the brain affected in dementia are the same ones that handle spatial navigation. So we as architects can really affect how people experience space through the design.

And so these dementia villages have really shown to be better in terms of quality of life. Residents are not needing psychotropic medications. Overall, staff are happier. And so we're starting to see that trickle into Canada.

I would say that with that type of model, we really need to do our due diligence and study the outcomes. You know, hearing anecdotal reports from residents and staff is great, and one set of data.

But we also need to do proper research studies to see if this is really a model we should be implementing all around the world.

Written by Jonathan Ore. Produced by Kate Cornick. Q&A edited for length and clarity.