The COVID-19 pandemic has rendered profoundly broad impacts across the globe ranging from the tragic loss of numerous lives to the everyday inconvenience of snarled supply chains. Furthermore, these impacts have affected every industry and population, few more acutely than clinical laboratories. Clinical and anatomic labs began and remain on the front line in fighting the pandemic by processing needed screening tests and conducting new research into improving disease outcomes. This is notwithstanding that prior to the pandemic, hospital labs were already quite busy managing a substantial complement of testing and other patient care activities. Accordingly, many institutions were already in need of expansion well before the pandemic introduced new testing streams and increased workloads.
Those that were investigating renovation or expansion of the laboratory operational space had common and consistent concerns:
As an understatement, the onset of the pandemic accelerated the need for action on all these points and more. Clinical labs began experiencing exponentially increasing microbiology volumes and the associated pressure to offer timely testing in service to both community patient populations and internal staff. Unfortunately, many labs had scant extra space for more equipment and proper adjacencies to existing equipment were rarer still. In an attempt to triage these challenges, some hospitals added space that was not contiguous to their main laboratories, while others displaced less critical testing equipment. Seen as less than ideal, many laboratories are now searching for remodeled designs and expansions that better accommodate current testing demands, as well as the flexibility to absorb future crises.
Forced Change versus Expected Change
In addition to accommodating higher testing volumes, other aspects of lab design have changed (perhaps permanently) as a result of the pandemic, including:
The process to expand a laboratory’s capacity—whether to accommodate generic growth or as the result of an emerging pandemic—is similar regardless and to be successful, should include input from multiple stakeholders.
Once a lab has been built and becomes occupied, lab managers adjust regularly to maintain optimal operation, whether this involves replacing and augmenting equipment, or repurposing underutilized space as needed. However, there is likely to come a point when the lab is not able to accommodate additional changes requiring a more significant assessment of workspace and operational options. At this point, evaluating design and build options for an existing lab should begin with a comprehensive review of current workflow operations (as well as ideal state operations) by lab management. Such a review should include, but is not limited to:
Benefit of Architecture & Engineering Consultants
After the initial assessment, representatives from the facility’s engineering group are usually brought into the discussion to advise on space availability and feasibility, as well as potential impact on the overall infrastructure of the facility. An architectural and engineering (A/E) consultant is likewise frequently added to the team, either to help implement the changes recommended by the facility engineering group or to develop more extensive options.
An A/E representative or team commonly begin the review process by surveying existing spaces and evaluating current and ideal work processes, flow, adjacencies, and support spaces. The analysis would continue with key staff interviews and mapping functional uses (eg, the amount of lab bench, storage, administrative, or other support space). Once the existing conditions and constraints are documented, assessment of space needs for additional staff, instrumentation, and equipment (including automation) would begin. Any new equipment, staff, or support functions would be given a space allocation, be tallied, and then added to the current total. Finally, depending on the magnitude of growth, the A/E team reviews options for internal expansion (renovation, including phasing) or external development (new construction).
As noted, the explosive growth in microbiology testing and concomitant need for additional equipment was an immediate effect of the pandemic. After testing expanded to new locations and even as individual volumes began to subside, in many cases, the space allocated to this additional testing became permanent. As a result of the COVID pandemic, many institutions have incorporated consideration of future pandemics into routine planning and actively discuss the inclusion of space for infectious disease research, including new or expanded biosafety level 3 or 4 spaces. Precious time was expended early in the pandemic to assess the myriad threats posed by COVID-19, and although many clinical labs did not need BSL3/4 spaces at that time, an equal or greater number see the vital need to be prepared for the next, inevitable pandemic.
Centralization through Design
With the advent of human genome sequencing, molecular biology has received substantial attention (and funding) in clinical laboratories and has been growing at a healthy rate ever since. Furthermore, this increasing interest in genetic testing for cancer and other diseases was joined by infectious disease testing, due in large part to the pandemic. One forecast estimated that the molecular diagnostics market will expand at a compound annual growth rate of 9.21% from 2021 through 2026,1 based largely on substantial interest in and concern for infectious disease diagnostics. This increase in molecular testing across differing subspecialties now commonly ends in the consolidation of molecular testing equipment into a central area.
Given the ongoing shortages of technologists, as well as an overall emphasis on the efficient use of resources, lab managers are grouping together instruments and equipment used for similar purposes—such as those between human leukocyte antigens (HLA), molecular pathology, and cytogenetics—and differentiating processes that are unique. Several functions that can be shared include specimen receipt and accessioning, refrigerated storage, and some extraction and pre-PCR equipment. To increase efficiencies, staff can be cross trained between these specialties and common storage needs can be consolidated. The FIGURE provides an example of how workflow can benefit from subtle change.
New Equipment Considerations
Clinical laboratory architects and designers are rethinking how different equipment lines impact lab design in the longer term. While there has always been a symbiotic relationship between the intended functions of lab equipment and the planning of the spaces that house it, an increased proportion of decisions are being made relative to the ability to expand existing space in a short amount of time and increase flexibility. For example, a single analyzer with a large footprint may prompt lab management to consider two smaller analyzers that could provide equal or greater throughput (as well as redundancy) in the same amount of physical space.
In the case of certain molecular testing equipment, an enclosed space is required in order to prevent sample cross contamination. However, in contrast, other testing equipment features internal sample containment during manipulation and analysis. These are considerations that affect flexibility and rapid expansion when necessary. The functionality of lab equipment, including processing throughput, reliability, and customer service, will always be driving factors in the selection process. But space constraints are becoming a critical part of the decision-making process, especially when space is limited and varying capacity is needed.
Supply Storage & Logistics
COVID-19 shutdowns and quarantines have impacted the entirety of laboratory supply chain management. The previously growing trend toward just-in-time delivery of lab kits and consumables became problematic when basic supplies (including masks and other PPE) could not be procured in a timely fashion. Some older labs never had sufficient storage space, while newer labs may have relied on just-in-time delivery to increase functional lab workspace at the expense of storage space. Both of these scenarios presented problems given the increase in testing complexity in recent years, which saw a resulting increase in required space for testing kits and supplies.
As a result, supplies often landed in “temporary storage” in hallways and corridors for lack of any other viable storage space. Accordingly, the pandemic has reinforced the need for specific strategies on supply storage and logistics; a concept once considered a luxury for clinical laboratories. While each laboratory discipline and department may desire large, individual storage spaces of their own, oftentimes, centralized storage, including refrigeration, is more efficient for space utilization and helps cut down on inventory management burdens for standard supplies.
A small amount of bench-adjacent storage for common daily supplies is always necessary, but a strategy should be sought for additional supplies to be housed in a central receiving/storage area or off-campus in a central warehouse building. Such a strategy enables the optimization of valuable lab space for testing, and storage to be housed in less expensive areas. Furthermore, off-site central receiving staff can serve to remove outer, corrugated packaging, thereby helping to avoiding dispersal of particulates into sensitive lab spaces which can, among other things, introduce calibration problems with certain instruments and equipment.
A Focus on Future Flexibility
The pandemic reinforced the absolute need for future flexibility in the lab to accommodate unexpected new volumes and equipment. Optimizing space is critical to most health care operations and the lab is no exception. Intake and accessioning need the unequivocal ability to handle any anticipated increase in courier traffic without interruption. Other operations can be planned adjacent to softer support spaces that can relocate when more testing capacity is needed. General office space is usually the easiest function to displace, and pathologist offices may provide an opportunity for lab growth.
A few organizations have recently severed the immediate adjacency between pathologist offices and anatomic pathology workspaces. That said, while digital technology adoptions and regulatory compliance have not been outsized issues, many groups were hesitant to lose the direct, hands-on connection provided by that adjacency. However, the risks and complications posed by the COVID-19 pandemic have drawn remote pathology sign-out into the mainstream. As many pathologists (and laboratorians) were confined to their homes for various COVID-related issues, the College of American Pathologists was one of several prominent voices advocating for remote sign-out capabilities. Accordingly, this experience may have helped change perceptions about the need for direct adjacency to the lab and enabled the separation of pathologist offices from the main lab for the foreseeable future.
Physical Casework and Fixtures
Flexibility in the lab also can be achieved through creative use of lab furniture, as opposed to relying on fixed casework. Given the number of modular and mobile instruments, gone are the days of new labs installing fixed casework with a 12-inch utility chase. The ability to quickly swap or rotate benchtop equipment with floor-standing equipment is becoming necessary to keep pace with a dynamic work environment. By adding flexibility in lab design and in the placement of instruments and furniture, utilities likewise can be strategically located to accommodate multiple configurations.
While power and data access points are relatively easy to modify without invasive renovation, adding new drains or water lines is more complex and can result in invasive, below-slab renovations if they are not planned for in advance. To assuage this problem, several recent laboratory clients have invested in raised access flooring so that all utilities could be more easily modified based on changing need. Similarly, some clients have installed water and drain access points (necessary for the initial installation of instruments and equipment), and then added additional access points in a regular grid pattern across the lab to fill in underserved areas. This option is less expensive than raised access flooring, less disruptive than having no additional service access, and still provides reasonable proximity to water in most areas of the lab.
In addition to the potential for increased testing volumes (due to pandemic, outreach, or any other reason), advances in instruments and testing methodologies now require the lab environment to be as adaptable and flexible as possible to accommodate inevitable changes.
As a result, laboratory design has several universal goals that focus on equipment, methodology, and workflow:
The pandemic has only served to reinforce these goals while challenging laboratory planners, designers, and architects to be creative when volumes suddenly spiked and staff safety hung in the balance. Learning from this experience will help the laboratory steel against future disruptions of this kind.
Debbie Phillips, AIA, ACHA, EDAC, is an accredited health care architect with aptitude and expertise to manage all aspects of complex health care projects. Her strengths include analytical ability and critical thinking, while her interests include health care and environmental research. Her broad background and experience in architecture encompasses programming, space planning, master planning, and design development.