When it comes to renovating a building for new or expanded use, there are few facility types more challenging than hospitals. The design standards are typically more complex and stringent than when the building was first constructed; technological advances necessitate support infrastructure that has to be retrofitted into the existing space, and budgets are often moving targets. If that were not enough to contend with, construction cannot interrupt critical patient care services.

Assessing the Need

The first step in any renovation project is to assess the need. In the corporate world, such assessments are often based on 5- to 10-year business plans that take into account sales projections, employment forecasts, strategic expansion plans, and other factors that may impact growth.

Looking that far out into the future is difficult, if not impossible, for most hospitals, especially in this era of consolidation and the changing missions and scope of health care providers. Also, hospitals often can¿t consider renovation or expansion plans until they have money in hand, sometimes from benefactors. And once they do have money, they must move quickly to develop and implement design and construction plans.

Assessing the Facility

The condition of an existing facility is a key determiner on whether or not it can be adequately and economically renovated. A thorough conditions assessment survey will help shed light on:

  • Structural elements such as interior columns, utility chases, ceiling plenum clearances, and maximum floor loadings. This is important for considering new interior space planning, location of mechanical equipment, placement of medical equipment, and routing of new ventilation duct systems, plumbing, wiring, and telecom cables.
  • Condition of plumbing, medical gas, water, sanitary sewer, and storm water systems and their ability to upgrade and expand.
  • Requirements for potable water protection of incoming mains and internal protection of the potable water system at connections to equipment, heaters, and boilers.
  • Life safety and ADA requirements.
  • Condition of building envelope with an eye toward the potential for enhancing the design and/or the need for improving energy efficiency.
  • Presence of hazardous materials such as asbestos and lead in the building itself, and the presence of buried storage tanks and other potential hazards on the property. The existence of internally lined ductwork or fiberglass duct board must also be evaluated in light of current and possible future IAQ issues.
  • Current code status. Hospital administrators need to be notified that any areas that are affected by the renovation must be brought up to current code standards.

Developing a Program

Once a conditions assessment survey has verified that a health care facility is suited to renovation, or that a building, in general, is suitable for conversion to health care activities, the design process can begin. The design should take into account not just the uses of the facility, but also the needs of the people who will work in the space.

Designers should solicit input from all the different users of the facility ¿ administrators, doctors, nurses, lab technicians, and other staff. These groups will occupy the space in different ways and at different times of the day and night, and letting them participate in the early design phase will help ensure creation of a functional and productive environment. The engineering and maintenance office should be consulted for their knowledge of existing conditions within the facility and for their plans for its future operation. The integration of these elements becomes the overall ¿facility program.¿

Guidelines for Design

The final design of a hospital ¿ whether new construction or renovation ¿ must meet strict regulations that cover every aspect of the facility¿s function and operation. The American Institute of Architects (AIA) has published Guidelines for Design and Construction of Health Care Facilities that is referenced by more than 40 states and the Joint Commission on Accreditation of Healthcare Organizations. The guidelines are updated every three to four years and are currently in a review/revision process.

The AIA¿s Guidelines set minimum standards for the design and construction of health care facilities and may be subordinate to more stringent state or local requirements. The Guidelines also refer hospital designers to more detailed standards set by a host of other code-setting organizations, including the American Society of Heating, Refrigeration and Air-Conditioning Engineers (ASHRAE), American National Standards Institute (ANSI), American Society of Mechanical Engineers (ASME), Illuminating Engineering Society (IES), National Fire Prevention Association (NFPA), Americans with Disabilities Act, Building Officials and Code Administrators International (BOCA), as well as such specialized organizations as the Centers for Disease Control and Prevention, College of American Pathologists, Compressed Gas Association, and the National Council on Radiation Protection.

Emphasis on Air Quality

Because of the high emphasis on patient comfort as well as the high risk of contamination in health care facilities, the AIA¿s Guidelines devote substantial attention to indoor air quality. Minimal ventilation requirements include:

  • Surgical and critical care areas ¿ 15 total ach including three changes of outdoor air, 30% to 60% rh, and 68? to 73? F temperature.
  • Patient rooms ¿ six total ach including two changes of outdoor air, no specific rh requirement and 70? to 75?F.
  • Labs ¿ six total ach, no specific rh requirement and 75?F.
  • Sterilizing and supply areas ¿ 10 ach, 30% to 60% rh, and 75?F.

Minimum filtration efficiencies include:

  • Inpatient care, treatment, and diagnosis areas ¿ two filter beds with 30% efficiency on the first, and 90% on the second.
  • Protective environment rooms ¿ two filter beds with 30% efficiency on the first, and 99.97% on the second.
  • Laboratories ¿ one filter bed with 80% efficiency.
  • Individual room air-handling systems must have filters with a minimum efficiency of 68%.
  • Air-handling duct systems must be designed with accessibility for duct cleaning and must meet fire protection requirements.
  • Ducts that penetrate construction intended to protect against X-ray, magnetic, RFI, or other radiation must not impair the effectiveness of the protection.

Other hvac guidelines include placement of air supply registers for operating and delivery rooms on the ceiling near the center of the work area, and return air registers located near the floor but at least 3 in. off the floor. On the exterior of the building, fresh air intakes must be located at least 25 ft from exhaust systems.

Phasing and Scheduling Construction

During actual construction, provisions must be made to ensure that interruptions to activities in adjacent or adjoining health care areas are minimal, and that health and safety are never at risk. Again, the AIA¿s guidelines set minimal standards with substantial emphasis on air quality. For example, the renovated areas must be isolated from the occupied areas during construction using airtight barriers, and exhaust airflow must be sufficient to maintain negative air pressure in the construction zone.

On a broader scale, phasing and scheduling should be carefully planned to provide continued access to drives, parking lots, and the building itself. Special attention should be paid to fire lanes, access for emergency vehicles, helicopter flight paths, and general delivery requirements. Because of the delicate nature of some modern surgical and treatment procedures, construction activities such as demolition or pile driving that may cause vibrations must be planned in accordance with treatment schedules. Reduction of vibrations as well as noise is also a general concern for providing comfortable care to patients. A phasing and scheduling program that accommodates the needs of medical staff, administrators, patients, and construction contractors requires significant communication and cooperation between all parties from the onset of the project and with daily coordination. If an environment of cooperation is created during the early planning stages, then the programming and designing of the facility should meet the goals and needs of everyone involved, and the actual construction should be completed with minimal problems.