April 2, 2020

Managing Access and Flow for Immunocompromised Patients’ Safety


It’s been just over five years since my father died due to complications from acute myeloid leukemia. When he was most vulnerable, he went through an unsuccessful (and potentially unnecessary, under the circumstances) surgery, after which he suffered an infection contracted through his incision that failed to heal. During his final weeks, we slogged to follow-up visits with his surgeon, and he exposed himself to many interactions with the public through the single entrance and exit from the surgeon’s office. I believe that had he not exposed himself to the procedure and the follow-up visits, he might have had more quality time with us.

Managing patient access to a healthcare facility is just one way to keep patients as safe as possible, especially when they are immunocompromised. However, this task can be a complex one, especially for a cancer center, where patients may be in various states of health and many services are offered in one building. While there are many important design considerations to keep in mind, such as branding and identity, aesthetics, separation of functions, and access to parking and travel distances, patient safety may be the most important reason to separate access for different patient types.

Haskell has been involved in dozens of operational and architectural projects for the design of buildings that provide cancer care. As a matter of course our planners study how patients, staff, and other visitors access the facilities they design. But in the midst of a global pandemic, these physical and process design solutions can’t be overstated. Here are some of the ways we manage access and flow.

Shorten distances from transportation to the door and then to service areas.

Providing valet parking service can alleviate the stress and strain patients in treatment may feel when coming to the center. Any self-parking patients should have only a short, direct distance to an entrance without having to cross other car traffic or traversing an incline, which may be particularly strenuous. Once a visitor is inside the building, services should be close to the door. Any circulation that is meant to get patients through a building or from Point A to B, and therefore may promote high traffic, should not be through highly clinical areas where patients in treatment could be waiting. If cancer services are provided in an acute hospital, then minimizing access and foot traffic that is not cancer-related will be important.

Separate “sick” patients from “well” patients.

Many cancer centers offer preventive screenings, such as mammography, to healthy people. Keep access to these services separate from other means of access to a facility, or in another facility altogether, to reduce traffic and exposure. If a patient must come for diagnostic testing, they may not yet be diagnosed “sick”; these patients could have diagnostic testing in a cancer center close to where the providers, such as radiologists, are practicing, but access to these services through a dedicated entry point might make sense to reduce traffic to any one entrance and segregate it from sick patients. Entrances to highly clinical areas such as chemotherapy or radiation oncology can be designed to promote less density. Likewise, patients in survivorship services or those visiting retail and complementary services provided in a less clinical and therefore less protected area could enter separately. Having separate entrances means patients, staff, and other visitors must understand which entrance to use, and this communication must be clear and entrances appropriately resourced.

Separate patients in process from those waiting.

Whether coming into a grand lobby or dedicated function area, patients seeking information or checking in should not be in close proximity to other patients or visitors waiting. Often we see that waiting areas by entrances are designed as holding pens where many different types of patients or visitors could be sitting together, and some of these could be immunocompromised. Instead, waiting areas can be adjacent but separate and should be specific to a treatment function. Seating can be spread out and segmented with partitions so that people are not seated on top of each other. And if at all possible, keep patients moving directly to their treatment area, without their having to wait at all. Many centers offer private waiting, such as for radiation treatment.

Separate adult patients from pediatric patients.

While there are many design reasons to separate these populations, such as aesthetic sensibilities, psychosocial needs, and different support requirements, pediatric patients can handle more aggressive treatment than adults and may have lots of side effects that would require more isolation.

Use no-touch systems and antimicrobial finishes.

Doors at an entrance should be automatic so that patients don’t have to touch anything. Technology that supports self-check-in, self-rooming, and/or automatic staff alerts of patient arrival can help reduce the need for a patient to stand in line, use a pen to sign in, or wait for service when they are more likely to touch things or be in close proximity to others. Countertops, furniture, and fixtures can all have an antimicrobial finish such as copper that reduces the chances of transmission of bacteria.

Determine whether a patient should come to the cancer center at all.

For patients who are in chemotherapy but need to travel a fair distance for treatment, a CBC test can be obtained at a smaller location closer to the patient, with timely results indicating whether a patient is well enough for chemotherapy. Saving a patient a trip until they are feeling better reduces unnecessary exposure. And with many oral chemotherapies being offered to patients, a growing number of patients can stay at home with companion monitoring telehealth visits with providers and nurse navigators.

Implement regular telehealth visits to gauge patient health and intervene before they develop complications.

It’s possible that some check-ups with patients do not have to be done in the cancer center at all but can occur via telehealth, particularly if the check-up is not on a treatment visit. For patients in cancer treatment, having telehealth access to a provider to inquire about potential complications, such as side effects, may elevate a patient’s priority to be seen for care before a patient becomes more severe, or may reassure a patient who may otherwise come for an unnecessary visit.

In the future, architectural planners will no doubt learn from changes to physical access that we are all currently experiencing due to the surge in COVID-19 cases. A cancer patient’s exposure to the virus could be catastrophic. How will facilities manage access if healthcare providers need to know a visitor’s illness status before their arrival at a facility? We may see phone apps help patients track daily how they are feeling and any symptoms, alert staff of visit need, or help manage those symptoms before a visit is needed. In China, police wear heat-sensing infrared devices that can check a person’s temperature from 15 feet away. Hypothetically, if these were available to staff at entrances, then some visitors could be treated more safely. It’s possible that screening or triage is needed at some cancer center entrances, such as it is in emergency departments. Surfaces may need wiping down much more often, particularly in high-traffic public areas such as lobbies and waiting.

As treatments and technologies evolve, cancer patient needs will evolve also, creating a need to provide access and service differently. Planners and architects will continuously need to adjust their approaches to these design challenges.

Haskell delivers $2± billion annually in Architecture, Engineering, Construction (AEC) and Consulting solutions to assure certainty of outcome for complex capital projects worldwide. Haskell is a global, fully integrated, single-source design-build and EPC firm with over 2,200 highly specialized, in-house design, construction and administrative professionals across industrial and commercial markets. With 20+ office locations around the globe, Haskell is a trusted partner for global and emerging clients.

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