Located at the centre of an urban area, but away from susceptible areas

Large-scale public venues often drive the economic development of urban areas and often located at the core of an urban spatial structure. If a pandemic affects a city dramatically, each venue in the centre of such an area can accommodate patients in this zone. This prevents the concentration of patients in a certain area which may result in cross-infection and increase the burden on medical resources and supplies. Meanwhile, the site should be away from high-density residential areas, schools and other densely populated areas in order to reduce the risk of virus transmission. In each district of Wuhan, one or two large-scale venues have been converted into Fangcang shelter hospitals. The deputy head of the district acts as the deputy director of the respective hospitals, and is responsible for managing and coordinating local medical supplies and other resources. The renovation of public venues in different areas can effectively relieve the urban emergency burden.

Accessibility

Large-scale public venues are often in the centre of a large metro area and are adjacent to multiple major arterial roads. Once these venues had been converted into Fangcang shelter hospitals as centres for receiving patients, supplies and staff support in that area, there was a high demand for convenient transportation. In addition, large-scale venues are often close to traditional hospitals, and patients whose symptoms deteriorate from mild to severe can be quickly transferred for further treatment. The Wuhan Living Room, for example, is located at the intersection of Wuhan’s rapidly developing urban area, which is surrounded by trunk roads, subways and other transportation systems. It is a 15 min drive from the Tianhe Airport or Hankou Railway Station. This advantage, which is also an important factor in normal circumstances, made possible the construction of the largest Fangcang shelter hospital within 5 days. Moreover, the hospital is only 836 m away from the Jinyintan Hospital, which is one of the most important designated hospitals in Wuhan. It is not only convenient for patients with severe to critical COVID-19 to be transferred to the Jinyintan Hospital promptly, but it is also conveniently placed so the hospital can send experts to the site for guidance.

Spacious outdoor area

Large-scale public venues, where various large-scale competitive sports are often held, have ample outdoor space. The spacious field facilitates the entry and evacuation of numerous vehicles and people.13 As a shelter hospital, the spacious outdoor field enables the rapid arrival and evacuation of ambulances, the construction of temporary auxiliary tents, and the installation of medical facilities. For example, in the Wuhan Living Room exhibition complex, the National Emergency Medical Rescue Team and the China International Emergency Medical Team (Shanghai) set up 7 tents as passage for health workers and 13 tents as command centres and auxiliary rooms, which connected to the remote consultation centre and became the core of the Fangcang shelter hospital operation (figure 1).

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Figure 1

National Emergency Medical Rescue Team and China International Emergency Medical Team (Shanghai) at Wuhan Living Room (https://www.thepaper.cn/newsDetail_forward_6733297)

Spacious indoor space

China’s rapid economic development has stimulated the demand by urban residents for cultural and recreational activities. Many cities have spacious large-scale public venues. Most of these venues are long-span structures or frame structures with flat space and a stable indoor environment which can accommodate a substantial quantity of people and equipment. The large-scale stadium can be easily renovated and partitioned, and can provide essential living conditions for a surge of infected people during a pandemic. For example, the Wuhan International Expo Center, which was one of the first to be converted into a Fangcang shelter hospital in the first batch, has a total construction area of 127 000 m². After the renovation, it provided 1600 beds and treated 1848 cases before it was closed.14

The power supply is reliable and easy to remodel

Large public venues often hold a variety of big events, which require highly reliable power supply. The power supply system of such places is highly reliable and is easy to remodel to serve different needs. Medical instruments such as CT equipment in Fangcang shelter hospitals have higher requirements for power supply, and large-scale venues can meet these requirements after minor remodelling. For example, in Wuhan Sports Center, the power distribution room uses dual power supply, and the two main power supplies both have a capacity of 3250 kVA, which has large-scale redundancy. The power supply system is equipped with a generator of 800 kVA and an emergency power supply of 750 kVA. These effectively ensure that the demand for important loads is not disrupted. Moreover, the Wuhan Sports Center has had practical experience in power protection for the 7th CISM Military World Games, and thus has a highly reliable power supply.15

In addition, these venues are required to meet the conditions for conversion into a shelter hospital, such as telecommunications, water supply and drainage, and fire safety facilities.

Architectural layout design and partition isolation

The architectural layout of a hospital follows the ‘three zones and two passages’ pattern, which includes a contaminated zone, a semiclean zone and a clean zone, passages for health workers, and passages for patients. A contaminated zone is the area where patients live and receive treatment, such as wards, treatment rooms, biohazard waste rooms, and patient admission and discharge registration rooms. The clean zone includes staff’s dressing rooms, catering services, duty rooms and warehouses. Semiclean zones are areas between the clean and contaminated zones, such as medical staff offices, nurse stations and other areas that may be contaminated by patients.

The ward should be partitioned and meet evacuation standards. In each zone, there should be no more than 42 beds but at least two evacuation exits. The width of the evacuation exit should be no less than 1 m per 100 persons, and the distance between anywhere to the evacuation exit should not exceed 30 m. The width of evacuation passages between the zones should not be less than 4 m. The partition should be made of fire-resistant material, and the height should not be lower than 1.8 m (figure 2).

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Figure 2

The layout of the Fangcang shelter hospital of Hongshan Stadium (http://www.xinhuanet.com/english/2020-03/03/c_138840039.htm)

The architectural design should also include essential living facilities, such as toilets, barrier-free access and storage rooms. For example, for toilet facilities, foam-blocked mobile toilets should be preferred, and medical staff’s and patients’ toilets should be separated. The men’s toilet is configured according to one positon per 20 men and one postion per 10 women. The number can be adjusted according to the actual situation. Toilets should be built downwind, away from dining areas and water points.

Ventilation

The ventilation and air-conditioning systems of large public venues are mostly positive pressure systems and only a few are negative pressure systems. This does not meet medical requirements. The remodelling of the ventilation system should make the best use of the original systems, and change the air supply and exhaust strategies to form a pressure gradient between the clean zone, the semiclean zone and the contaminated zone.

Air purification and disinfection devices should be used for air-conditioning systems in a contaminated zone and a semiclean zone. If possible, the air-conditioning unit can be equipped with a clean air-conditioning system, and an ultraviolet disinfection lamp can be installed near the return air filter and the surface cooler. The exhaust air volume should be designed to be no less than 150 m³/hour per person.

Sewage

The sewage from Fangcang shelter hospitals cannot be directly discharged. Temporary tanks for sewage treatment should be set up. Chlorine and peroxyacetic acid can be applied to sterilise and disinfect the sewage. Using mobile hospital-specific plasma equipment for sewage treatment is also feasible. It is important to install an automatic monitoring system for water quality inspection at the treated sewage outlets to ensure that the discharged sewage meets the standards (figure 3).

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Figure 3

Renovation for sewage treatment at a Fangcang shelter Hospital (http://www.sasac.gov.cn/n2588025/n2641611/n4518442/c13881088/content.html)

Fangcang shelter hospitals were not included in the emergency action plan for epidemics

In the early stage of the pandemic, Wuhan did not immediately implement measures to convert existing large-scale public venues into Fangcang shelter hospitals. Instead, new temporary hospitals were built, such as the Huoshenshan Hospital and the Leishenshan Hospital, but their capability and capacity to admit, treat and quarantine patients were limited. In future urban planning and emergency action plans, large-scale public venues in cities should be prepared to be converted to medical emergency sites during disasters. The local emergency action plan should include details of the large public venues, together with the prerequisites and procedures for renovation.

Large public venues are less prepared for conversion into emergency shelters

The renovations can involve some complicated construction work, such as the remodelling of ventilation systems. Some Fangcang shelter hospitals were still undergoing construction of ventilation systems when they started to admit patients. In the future, medical emergency shelters should be included in the architectural design and construction plan of designated large-scale public venues. For example, the layout for a temporary hospital, including ward zones, treatment and work stations, should be planned in advance, and the installation interfaces of the ventilation system and sewage treatment system should be reserved, in order to manage air pressure gradient and prevent nosocomial infection in the future. During the initial design stage of large public venues, preparing for multiple disasters such as earthquakes, floods and fires should also be considered, and also provide interfaces for converting them into shelters during disasters. This can be summarised as the goal of ‘One investment, Comprehensive disaster prevention’.

Insufficient on-site management experience in Fangcang shelter hospitals

During the early stage of operations of Fangcang shelter hospitals, some problems emerged which reflected insufficient on-site management experience, such as confusion with responsibilities and the high turnover of medical staff. The working team in Fangcang shelter hospitals was temporarily composed of local government and medical rescue teams from other provinces. Clarifying each person’s responsibilities and ensuring the stability of the team are prerequisites to the effective operation of a shelter hospital. First, the government, community and medical rescue team should clarify their responsibilities. Government staff are responsible for hospital construction and deployment of resources. Community workers are responsible for maintaining the order of patients in the hospital, and medical staff are responsible for medical assistance. Second, the main function of Fangcang shelter hospitals is the admission and isolation of patients with mild symptoms, and thus require fewer medical staff. The medical manpower can be reasonably allocated to avoid waste of medical resources. Finally, medical rescue teams from other provinces should be planned and assigned holistically. Transferring medical staff back and forth between different Fangcang shelter hospitals should be avoided in order to reduce the risk that comes with medical staff not being familiar with the new hospital and the patients.