Healthcare's ultra-tech revolution, once stalled by government regulations, approvals processes, and institutional roadblocks, is propelling the healthcare field into a new era, one requiring more rigorous and thoughtful planning and collaboration by Building Teams.
Advances in medical and information technology are affecting every area of the hospital: operating rooms, patient rooms, emergency departments, nursing stations, and administrative support services. Medical technology is a major reason why healthcare has been the best-performing sector in the nonresidential building industry in recent years. Healthcare facility owners, struggling to keep pace with the rapid evolution of medical technology and IT systems, are spending big bucks to renovate, expand, and build new facilities, all the while holding their breath that the facility won't be outdated by the time it's built.
The lightning speed of these advances is bewildering, as Building Teams plan and design hospitals, only to find the technology has outpaced their best efforts. "You have to plan for the obsolescence of technology," says Ralph Hawkins, FAIA, FACHA, president of architects HKS Inc., Dallas. "Flexibility for growth and change is key."
Hospitals are moving toward greater uniformity through the use of one-size modular structural bays, universal rooms, and uniform corridor widths, says Robert Levine, VP/GM of Turner Construction Co.'s Brentwood, Tenn.-based healthcare group. "This gives hospitals added flexibility as they grow or shrink."
Healthcare owners are relying on architects, mechanical and electrical subcontractors, and equipment planning consultants for advice on equipment purchases, such as diagnostic imaging machines, wireless tablet PCs, and automated medication delivery systems. "From the time a building is designed until construction begins, it may be two years before move in," says Jim Koehler, director of telecommunications for healthcare specialists Hammel Green and Abrahamson, Minneapolis. "Because the technology is changing so quickly, we try to keep current, help our clients understand the latest technology, and design the hospital accordingly."
But with medical technology changing so fast, "early selection of equipment is no longer desirable," says Turner's Levine. "The implementation of universal utilities equipment allows for the latest possible selection, which gives hospitals an edge in obtaining the most up-to-date technology." Under the universal utilities concept, instead of designing and installing access to either electric and gas or electric and steam into specific locations, access to all three utilities is designed in to accommodate equipment that uses either type of hook up. This allows construction to move forward without adversely impacting the future selection of equipment.
In this climate, the designer has "become much more of a facilitator in helping customers identify their operation strategies," says Stan Parnell, associate VP and medical planner/designer in architect RTKL's Dallas office. This cannot be done properly without evaluating the technologies the hospital wants to put in place, he says. "Owners shouldn't look at their approach without looking at the technology. The two go hand in hand."
Of course, all this has to be done within the client's budget. "You try and figure out what the demand is likely to be and plan for that within the financial constraints," says HGA's Koehler. Nonetheless, says Giles van der Bogert, AIA, managing partner and principal in charge of the healthcare practice at Loebl Schlossman & Hackl, Chicago, "More of the owner's limited dollars are going into IT and technology than ever before," leaving less available for other parts of the program.
Let's take a look at how these technologies are impacting healthcare design and construction.
As diagnostic imaging machines, robotics, and video cameras find their way into already crowded operating rooms, ceiling-mounted overhead booms are freeing up floor space while making the rooms better organized and safer. Medical gas delivery can be accessed from the boom, while wiring and cabling can be housed in its throat, eliminating unsafe wires and cables on the floor. Equipment sits on stands attached to octopus-like articulated arms extending outward from the boom's main column.
Articulated booms are being used in operating rooms in Ontario’s Toronto General Hospital, designed by HOK.
"Booms are the big thing in ORs," says Robert Larsen, FAIA, managing partner of New York-based healthcare design specialist Larsen Shein Ginsberg Snyder (LSGS). Now, with "so many new elements in the OR, there may be as many as five arms extending off of three booms that are suspended from the ceiling: one dedicated to the surgeon's equipment, one to the anesthesiologist's equipment, and one for lighting, medical gases, and other equipment," says Larsen.
The ceiling structure must be designed or strengthened to support these booms, which can literally weigh a ton when fully loaded. To reduce these loads, lighter but more expensive flat-screen monitors have replaced conventional monitors. Thought also must be given to space requirements for the booms, as well as the number of data ports that they must support.
Booms aren't cheap, leading some to refer to them as "a $20,000 solution to a $2,000 problem," says Scotty Ferris, senior project manager for EQ International, a Dallas-based medical technology planning consultant. He defends the capital cost by saying the booms pay for themselves in reduced wear and tear on equipment. And by keeping things off the floor, they also make it easier to sterilize ORs and turn them around faster for use.
Booms are also being installed in intensive care units. Because the equipment is not anchored to a wall, beds can be pulled away from the wall, giving caregivers and family members 360-degree access to the patient, notes Mark Moody, corporate director for engineering services for Mountain States Health Alliance, Johnson City, Tenn., which is installing booms in a renovation of a 28-bed ICU at its medical center in that city.
In renovating the 54,000-sf adult critical care department at New York's Bellevue Hospital, Robin Guenther, AIA, principal of Guenther5 Architects, New York, says booms enabled the design of a single room type that could accommodate both surgical and neurosurgical patients. "The virtue of the boom is that it allows the bed to be placed in the middle of the room," says Guenther. Thus, for surgical patients, caregivers can gain access to numerous patient surgical sites, while for neurosurgical patients, they can have access primarily to the head.
The introduction of robotics into the OR in the last few years has added to the need for space and IT cabling connectivity, says LSGS's Larsen. Twenty years ago, ORs occupied 400 square feet, but today 600 is the norm, "and it's not unusual to see them go larger," says Larsen, in part because the surgical robots alone take up about 200 square feet of floor area. In fact, the OR suites he designed last year at Johns Hopkins Medical Center in Baltimore were 800 square feet.
Positioned at the patient's side, the robot is controlled by a surgeon sitting at a separate console. Three years ago, as part of a renovation of a surgical suite at Maimonides Medical Center in Brooklyn, N.Y., LSGS transformed a physicians' lounge into a robotic operating room, with the control console housed in an alcove in the OR.
Technological advances and changes in surgical procedures have transformed imaging departments into one of the most dynamic areas in a hospital. The traditional line between imaging and surgery is being blurred, with MRIs being used more in surgical ORs and imaging equipment being used in minimally invasive outpatient surgical procedures, such as cardiac catheterization.
Digital Web-based picture archiving communication systems (PACS) produce filmless images, eliminating the need for cumbersome radiological film and the accompanying darkrooms, bulky viewing boxes, and film storage. PACS images can be stored electronically and transmitted via the hospital's data network to viewing stations throughout the hospital — even to physicians' homes. Streamlined diagnostic viewing rooms contain up to three viewing stations, which resemble control consoles equipped with flat-screen monitors. Design teams need to know where the client wants to place the viewing rooms: "You have to be mindful of patient confidentiality because of HIPAA regulations," says RTKL's Parnell, referring to the privacy requirements of the 1996 Health Insurance Portability and Accountability Act. Designers must ensure that the PACS's archiving and retrieving capabilities are tied into the hospital's data network.
The PACS system at the new George Washington University Hospital in Washington, D.C., stores data electronically on a secure Web server, says radiologist Robert Zeman, professor and chairman of radiology for the hospital, which was designed by HKS. "Because the images are readily available, physicians are able to make clinical decisions more quickly," says Zeman.
In some instances, architects are being asked to design traditional radiographic rooms in new or renovated facilities, but plan for the costly transition to digital PACS. "Now you're providing for both film and digital environments," says Annie Coull, AIA, ACHA, principal with San Francisco-based Anshen+Allen. "The lighting needs are quite different for digital environments, and the use of film affects workflow."
In addition to its use as a diagnostic tool, imaging technology is being used in interventional procedures. Its growing presence in the OR has made the imaging department "the fastest-growing area in the hospital," says Chuck Siconolfi, ACHA, AIA, director of healthcare planning and design in HOK's New York office.
Further blurring the lines is the trend in hospitals to merge the different forms of technology into undifferentiated "technology floors," says Guenther5's Robin Guenther: "The idea of strict departmental technologies based on strict disciplines is beginning to give way."
In the last three years, for example, about two-thirds of all cardiac surgery caseloads have moved from the surgical arena into outpatient cardiac catheterization, a minimally invasive procedure performed using image-guided equipment. Putting both therapeutic and diagnostic functions in the same room has led to the creation of the interdisciplinary interventional suite and the need for added support space.
"Ten years ago there was very little need for patient preparation and recovery areas in imaging departments," says HOK's Siconolfi. Now, he says, projections are that between 2000 and 2010, the need for space in imaging departments will increase by a factor of five.
Conducting more interventional procedures outside the operating room raises concerns about infection control and sterilization in these interventional suites. Design teams need to consider the flow of materials in and out of these areas, and even whether to put sinks in the rooms. "ORs never have sinks in them, but imaging areas traditionally do," says Coull. "The priority should be to develop interdisciplinary interventional suites with multiple levels of procedural care."
To reduce the risk of infection in long surgeries, design teams are creating super-clean surgical environments in the immediate area surrounding the patient. Particular attention is being given to air-supply delivery, with 10-20 times the typical air volumes being pumped into these rooms, says Larsen. To further fight infections, plastic curtains are installed, creating a 10x10-foot surgical field.
Wireless bedside charting systems — including portable tablet PCs, handheld personal data assistants (PDAs), and Internet protocol phones — are enabling Building Teams to decentralize nursing stations. Patient rooms can now be organized into pods of four to six beds, with nursing workstations located in alcoves in the hallway of each pod.
"I don't think the decentralized nursing model works unless you have that level of communication," says Steve Pelton, a regional chief information officer at Ministry Healthcare. When the Milwaukee-based system opens its $84 million, 107-bed St. Claire's Hospital in Weston, Wis., next year, the nursing staff and physicians will be issued tablet PCs to access patient charts at bedside. Docking stations will be provided at the nursing alcoves located in the hallway outside of every two patient rooms, as well as on rolling mobile medicine carts.
PDAs are getting a trial in George Washington University Hospital's pilot PDA program. Physicians have on-line, real-time mobile access to patient data and soon will be able to key in lab tests and X-rays as well as order medications using the devices.
A pneumatic tube system allows nurses at George Washington University Hospital in Washington, D.C., to receive and send information, such as medications and lab results, throughout the hospital.
Internet protocol phones are also making headway. George Washington University Hospital has replaced noisy intercom systems and flashing lights with IP phones, which function as a telephone, silent pager, and nurse call device.
With the ability of wireless and digital technologies to link directly into a hospital's electronic data network, many healthcare institutions describe their operations as "paperless." But while they are heading in that direction, they are more "paper-light environments," says RTKL's Parnell, because of laws that require paper documents and because paper will still come into the hospital from physicians' offices, nursing homes, and insurance companies.
"My definition of all-digital is that there are no permanent paper archives," says Ministry Healthcare's Pelton. St. Claire's will have no medical record storage because "the paper we receive from outside sources or generate during a patient visit will be scanned into a digital format."
In today's healthcare environment, medical technology and information technology "are becoming so integrated that they are nearly one and the same," says RTKL's Parnell. Large-scale hospital systems are upgrading their IT infrastructures, enabling support services, such as billing, payroll, finance, marketing, and human resources, to be located off-site.
"A lot of larger healthcare systems are centralizing their support departments," says Loebl Schlossman & Hackl's van der Bogert. "IT is allowing them to better utilize space in the hospital for patient care."
Together, IT and medical technology are having the biggest impact on real estate decisions for healthcare providers, says van der Bogert. "It's changed how owners look at real estate utilization." For example, while Milwaukee's Ministry Healthcare is meshing its medical equipment at St. Claire's with its IT, it also is locating its support services to a nearby office location separate from the hospital, says Pelton.
The continuing interplay between medical technology and IT is making it even more necessary for Building Teams to "integrate much earlier and in greater detail with the owner than in the past," says Parnell.
Medical technologies making an impact on hospital design
|Medical technology||Where used||Impact||Design implications|
|Ceiling-mounted articulated booms||OR, patient room, ER||Placing equipment on articulated arms frees up floor space, reduces "spaghetti factor" trip hazards||Space configuration, IT connectivity|
|Robotics||OR||Enhances surgical operations||Space configuration, IT connectivity|
|Digital Web-based PACS systems||Imaging, OR||Produces filmless images, eliminating need for radiological film storage and accompanying darkrooms, viewing boxes||Reduces film storage needs and changes requirements for viewing rooms and stations|
|Imaging for outpatient interventional procedures||Imaging||Leads to creation of interdisciplinary interventional suites where both diagnostic and interventional procedures are conducted||Room size, space planning for preparation and recovery, sterilization requirements, IT connectivity|
|Imaging in OR||OR||Placement of control consoles in OR||Space configuration, IT connectivity|
|Wireless tablet PCs, PDAs, IP phones||Inpatient bed units, nursing stations||Enable decentralized nursing station design, bedside charting for instant access and updating of patient records and medication orders, convenient and quiet nurse call system||Space requirements for antenna installations, IT connectivity|
|Automated medication dispensing machines||Nursing stations, nursing alcoves||Reduces medication errors, automatic charge capture, and inventory control||May eliminate need for medication supply rooms, space required for machines in nursing stations and alcoves, IT connectivity|