THE PROBLEM
The ongoing COVID-19 pandemic has revealed profound weaknesses in the way Canadians are accommodated as they age and require more support. It has become evident that the very design of the buildings in which they reside greatly affects the health and safety of residents and staff members. The crowding of multiple residents into bedrooms and shared bathrooms provides ideal conditions for the spread of infections – not only COVID-19, but Clostridium difficile, Febrile Respiratory Illnesses, Methicillin-resistant Staphylococcus aureus and Vancomycin-resistant enterococci to name a few.
The figures are devastating.
As of July 2022, the National Institute on Aging (NIA) recorded COVID-19 outbreaks across 3,820, or 63% of Canada’s long-term care (LTC) and retirement homes and identified 107,461 resident and 58,715 staff cases. Additionally, they recorded 17,177 resident and 32 staff deaths which account for 43% of Canada’s overall deaths [1]. Furthermore, during the first wave, 81% of COVID-19 deaths occurred in LTC and other congregate settings. This was almost twice the international average of 38% in member nations of the Organisation for Economic Co-operation and Development (OECD)[2]. NIA researchers also identified that there were 74 times more deaths of elderly Canadians living in LTC and retirement homes than among their community-dwelling counterparts — 3 times greater than the OECD average[3].
The basic physical design of LTC homes is a significant contributing factor in the spread of COVID-19 and other infections. Shared bedrooms and bathrooms in LTC homes are clearly associated with larger and deadlier COVID-19 outbreaks. A study of Ontario LTC Homes in 2021 used simulations to determine that converting all multiple-resident rooms to single-resident rooms would have prevented 1641 infections (31.4%) and 437 deaths (30.1%)[4].
Research validates what appears to be common sense, that shared spaces (bedrooms and bathrooms) create ideal environments for the spread of illness in a vulnerable population that has few recourses to protect itself. Despite the clear evidence, two recently released key standards and the National Building Code of Canada (NBCC) fail to address the need, on the basis of fundamental health and safety, to eliminate shared bedrooms and bathrooms in Canada’s LTC homes.
The Health Standards Organization (HSO) has recently released a revised standard on Long-Term Care Services[5]. The Canadian Standards Association (CSA) has released a complementary standard entitled Long-term care home operations and infection prevention and control[6]. While the HSO standard focuses on care, the CSA standard focuses on infection prevention and control. While both standards contain many positive measures that should be implemented, they are regrettably flawed on critical matters related to crowding.
The HSO standard fails to recognize that the design of LTC buildings significantly affects the delivery of care and that crowding of residents compromises their health. The CSA standard does consider the building design, suggesting, but not mandating that all resident rooms be single occupancy. It also suggests, but again, does not mandate, that each resident bedroom has its own bathroom.
The National Building Code of Canada (NBCC) is a model building code that is updated on a five-year cycle. It establishes technical requirements for the design and construction of new buildings, as well as the alteration and change of use of existing buildings. The NBCC is intended to ensure the health and safety of occupants of buildings. The forthcoming edition will reportedly incorporate 280 changes, however it does not appear that any are related to physical health and safety.
A SOLUTION
The RAIC believes, on the fundamental basis of health and safety of vulnerable residents, that shared bedrooms and bathrooms must be prohibited in all new facilities and that over time must be eliminated in existing facilities. Beyond health and safety improvements, private rooms and bathrooms greatly improve the overall quality of life of residents.
The RAIC not only calls for revision of the HSO standard to address the important factor of crowding, but also that the CSA standard to go a step further and mandate single occupancy bedrooms and bathrooms. Furthermore, once updated, both standards should be adopted by Provincial and Territorial governments as compulsory standards governing the design and operation of LTC homes.
It is very disturbing that the hard-learned lessons of the COVID-19 pandemic have not resulted in obvious and urgently needed changes to the standards and codes used to govern the design and operation of the next generation of LTC homes and the renovation and upgrading of existing ones. Some of Canada’s provincial and territorial governments and regulators are content to use outdated standards and codes and to continue to build unhealthy and unsafe LTC homes.
Without these bold changes, Canada’s LTC population will continue to be exposed to conditions that increase risk of deadly infectious diseases. The RAIC reiterates these recommendations to the Canadian Board for Harmonized Construction Codes (CBHCC) and the National Research Council of Canada’s (NRC) Codes Canada.
THE BROADER ISSUES
The institutional/medical LTC model that prevails with its funding, outdated operational policies and poor design standards, although at a lower cost than hospital accommodation, does not respect or support a resident’s needs for living with dignity. Further, there are other home and community models of support that have proven to be much more humane and cost-effective [7]. A 2020 survey validates that Canadians do not want to live in most long-term care facilities, with particular concerns about exposure to health risks [8, 9].
Architects have a responsibility to advocate for Canadians and to create spaces that meet their needs and advance the public interest. Architects advocate for a new vision: places to live and to call home, and where there is support to live one’s life to the fullest possible – to one’s last breath.
Canadian architects know that sensitive design offers a range of greatly improved accommodation options that promote well-being. The RAIC’s position is that alternative approaches to the accommodation of aging Canadians needing support are essential, and are a human rights and social justice issue, and we are committed to collaborating with governments, regulators, owners, and operators of facilities, as well as aging Canadians and their families to develop dramatically improved supportive places to live.
Beyond immediate needs to address health and safety issues in standards and codes, there must be a shift of accommodation strategies from medicalized and institutionalized environments in which residents’ quality of life is the result of numbers fed into formulas, to strategies that ensure aging Canadians live with dignity and respect with as much independence as is possible. There are many instances in which architects’ designs have supported innovative and superior accommodation models.
ABOUT THE RAIC
The Royal Architectural Institute of Canada (RAIC) is a not-for-profit, national organization dedicated to representing architects and architecture since 1907. The RAIC is the only national voice for excellence in the built environment in Canada focused on providing Canada’s architectural community with the tools, resources, and education to elevate their practice. The RAIC is committed to showcasing how design enhances quality of life, while advocating for important issues of society through responsible architecture. The RAIC’s purpose is to create a better world for all by empowering Canada’s architectural community. Through our work, the organization envisions a strong architectural community that is valued and empowered to create change.
The RAIC is grateful to the members of the Long Term Care Working Group who have contributed to the development of this statement.
REFERENCES
1 National Institute on Ageing (2022). Counting COVID-19 in Canada’s Long-Term Care Homes: NIA Long-Term Care COVID-19 Tracker Project Summary Report. Toronto, ON: National Institute on Ageing, Toronto Metropolitan University. Retrieved from: https://www.nia-ryerson.ca/s/NIA_LTCtracker_V6-Final.pdf
2 Canadian Institute for Health Information. (2020). Pandemic experience in the long-term care sector: how does Canada compare with other countries?. Ottawa, ON.
3 National Institute on Ageing. 2021. Pandemic Perspectives on Long-Term Care: Insights from Canadians in Light of COVID-19. Toronto, ON. Retrieved from: https://www.nia-ryerson.ca/s/English-NIA-CMA-Report.pdf
4 Brown, K. A., Jones, A., Daneman, N., Chan, A. K., Schwartz, K. L., Garber, G. E., ... & Stall, N. M. (2021). Association between nursing home crowding and COVID-19 infection and mortality in Ontario, Canada. JAMA internal medicine, 181(2), 229-236. Retrieved from: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2772335
5 CAN/HSO 21001:2023 - Long-Term Care Services, published January 2023 by the Health Standards Organization (HSO). Retrieved from: https://healthstandards.org/standard/long-term-care-services-can-hso21001-2023-e/
6 CSA Z8004:22 - Long-term care home operations and infection prevention and control, published December 2022 by the Canadian Standards Association (CSA). Retrieved from: https://www.csagroup.org/store/product/CSA%20Z8004:22/
7 Zimmerman, S., Dumond-Stryker, C., Tandan, M., Preisser, J. S., Wretman, C. J., Howell, A., & Ryan, S. (2021). Nontraditional small house nursing homes have fewer COVID-19 cases and deaths. Journal of the American Medical Directors Association, 22(3), 489-493.
8 Leroux, M. L. (2021). Nursing home aversion post-pandemic: Implications for savings and long-term care policy.
9 Achou, B., De Donder, P., Glenzer, F., Lee, M., & Leroux, M. L. (2022). Nursing home aversion post-pandemic: Implications for savings and long-term care policy. Journal of Economic Behavior & Organization, 201, 1-21.