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Operation Medical Surge

EXPANDING HOSPITAL BED CAPACITY IN WASHINGTON DC IN RESPONSE TO COVID-19

BY ADAM JACHIMOWICZ

443 beds. A hospital-grade liquid oxygen farm. Industrial HEPA filtration. A rapid treatment center, a pharmacy, a laboratory. Building a makeshift hospital is no easy task, and these are just a few of the many features that engineers must often design for. Finishing the job on time in the thick of a pandemic, no less, is another kind of challenge altogether. But federal and local agencies did exactly that in Washington, D.C. at the outset of COVID-19, creating the city’s third largest hospital in the Walter E. Washington Convention Center — and they got it done in just 17 days.

The original USSAVE, Events DC and HSEMA assessment team

Mayor Muriel Bowser declared a state of emergency in Washington, D.C. on March 11, 2020, activating emergency protocols under the Department of Health (DOH) and the Homeland Security and Emergency Management Agency (HSEMA). Facing a bed shortage in the thousands, emergency managers proposed an Alternate Care Site (ACS), or temporary hospital, to meet additional capacity. A single, large facility would do, as would hotels and universities, or perhaps some combination of the three.

Ultimately, the Washington Convention Center stood out among 40 other sites, providing a large, state-of-the-art, centrally located facility ready for conversion. Just one of the Center’s five ‘halls’ offered sufficient space for construction, and in fact, all five ‘halls’ could accommodate roughly 1,900 beds, with other areas on-site providing about 750 more if needed. In addition to its existing fire suppression, ventilation and backup power systems, the center also included an underground utility corridor for water supply, waste and electricity, as well as ADA-approved bathrooms. Lastly, while the center was a bit too far from any one hospital to serve as an extension of that hospital itself, it was fairly equidistant to all the hospitals in the area. Given the District of Columbia’s concentrated geography, centralizing care seemed like an appropriate way forward.

Once Mayor Bowser approved the Washington Convention Center for construction, the city government submitted a formal request to FEMA. FEMA, in turn, tasked the Baltimore District of the U.S. Army Corps of Engineers with design and execution. The Corps had already begun similar build-outs nationwide, and by that time, had helped assess the feasibility of the center itself. Washington, D.C.’s chief building inspector, chief code official, and fire marshal soon joined the team, along with representatives from the D.C. National Guard and Air National Guard, as well as the Department of Health and Human Services. Events DC, which owns and operates the center, and MedStar Health, the clinical operator, similarly integrated their expertise from the very start.

While synthesizing these perspectives became challenging at times, including a breadth of information early on in the design process proved instrumental. Moreover, with the unprecedented nature of the pandemic itself, leadership favored a horizontal approach to disaster management over the vertical, tiered framework conventionally employed. Stakeholders weren’t simply customers, clients or regulators — above all, they were team members with a single, clear mission in mind: to build more beds, fast. Transparent exchange forestalled the command-and-control issues that often arise, paying substantial dividends in quality, speed and cohesion.

Hall A of the Walter E Washington Convention Center was used for the temporary COVID hospital.

The team advertised a scope of work on April 12, less than a week after the FEMA request, and awarded a $31.7 million contract to Hensel Phelps, a member of multiple AGC chapters, just two days later, on April 14. Construction began on April 22 with three shifts across 24 hours. The first and second shifts prioritized production; the third shift worked overnight on cleaning and preparation. Three subcontractors participated as well, bringing the crew to about 700 workers in total.

Around the same time, just a few weeks into the pandemic, a number of alternate care sites just like this one began to pop up nationwide. While each of these sites shared the same essential function — to augment existing hospital capacity — they were first and foremost designed with non-COVID patients in mind. Hospitals, the thinking went, would discharge non-COVID patients to the alternate care facilities in order to open up bed space for COVID-patients instead. But hospitals benefit from retaining existing patients, so this assumption overlooked the basic economic incentive of private medicine, and often with catastrophic consequences.

With this lesson in mind, the team in Washington, D.C. prioritized making its own alternate care site ‘COVID-capable’ from the outset. In other words, the center would need to be outfitted with everything an existing hospital would need to treat a COVID patient — and above all, that meant oxygen. Portable oxygen cylinders could supply a little over half of the beds, but equipping the entire facility with cylinders alone would prove a bit too cumbersome under the circumstances. Instead, the team opted to build a liquid oxygen farm from scratch, right on the roof of the building, to accommodate the remaining beds.

Each of the 443 beds would be housed inside a ‘room’ with hard wall partitions. Each room, in turn, would include a pre-fabricated headboard with eight electric receptacles; power switches and a USB charger; room, exam and night lighting; a wireless call system for nursing staff; and a piece of artwork donated by a local artists’ group. Ceilings could be done without, as they would require additional sprinkler, ventilation and emergency lighting systems. The rooms would run perpendicular to each other in 12 columns, all within a negatively pressurized hall with hospital-grade HEPA filtration systems. A spine right down the middle would contain nurse stations and storage rooms. The north side of the spine would include positively pressurized shower and support stations, keeping contaminated air from the hall at bay. An operations center just outside the main hall would serve as the facility’s centralized command.

The alternate care site has a capacity of 443 bed spaces and could be expanded if needed.

Despite the complexity of this effort, the team managed to complete construction in under three weeks. Its durability reflects the merits of a time-tested, three-pronged approach adapted to the circumstances of the pandemic itself. Three takeaways from this effort that may be translated to any effort to support a rapid increase in
capacity:

  1. Unifying a diverse team to synthesize multiple forms of expertise. The team streamlined the design process by working across sectors and silos from the outset.
  2. Executing a single, clear mission. The team focused its efforts on augmenting existing hospital capacity, even amid a rapidly evolving — and unprecedented — state of emergency.
  3. Sharing information to mitigate risk. The team drew lessons from parallel missions nationwide, and in doing so, learned to prioritize a ‘COVID-capable’ environment within the ACS itself.

If this effort might serve as a blueprint for future projects, particularly throughout the pandemic, its success will rest firmly in its spirit of collaboration, understanding, and camaraderie.