ARCHITECTURE H E A L T H S C... f o r t h e

ARCHITECTURE
for the
HA p u b El i c a t Ai o n o fLF R ATN C I SHC A U F F M A SN N F OCL E Y HIO F F EM A N NN, A R CCH I T E CET S L TSD .
E M E R G E N C Y
D E PA R T M E N T S :
The New
Front Door
page 12
ARCHITECTURE
for the
H E A L T H
S C I E N C E S
Volume 1 • Issue 1
A publication of
Francis Cauffmann Foley Hoffmann, Architects Ltd.
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Architecture for the Health Sciences
FROM THE PRESIDENT
Francis Cauffman Foley Hoffmann, Architects Ltd. is pleased to present the inaugural
issue of Architecture for the Health Sciences. This magazine will focus on emerging
trends in:
•
•
•
•
Healthcare
Academic Research and Sciences
Corporate Research
Medical and Higher Education
Architecture for the Health Sciences will be published semi-annually to keep its readers
on the leading edge of strategies, tactics and technologies that will facilitate their growth
and change.
As a Creative Enterprise, Francis Cauffman Foley Hoffmann, Architects Ltd. places a premium on expertise, innovation and execution. The articles contained herein are, and
always will be, written by national experts on the topic. You will find actionable intelligence regarding industry trends, process change and new technologies.
On behalf of Francis Cauffman Foley Hoffmann, Architects Ltd., I thank our clients and
consulting partners for their support advancing our expertise and collaborative approach.
For 50 years, Francis Cauffman Foley Hoffmann, Architects Ltd. has been an information
resource to its clients. Our innovations and benching have fueled our clients’ growth.
We bring this energy to light in Architecture for the Health Sciences, and look forward
to supporting you.
Sincerely,
James Crispino, AIA
President
TABLE OF CONTENTS
Planning for Bioinformatics Facilities................................................................................4
by Glen E. Conley, AIA
Careful Emergency Department Planning Can Increase Market Share ..........................8
by James T. Crispino, AIA
Emergency Departments: The New Front Door ............................................................12
by Beth Leslie Glasser, AIA
Case Study: Consolidating Multiple Laboratories..........................................................18
by Edgar G. Bermudez, RA
State University of New York at Stony Brook
Case Study: Doing A Lot with A Little ............................................................................24
by Thom L. Lehnam, AIA
Architecture for the Health Sciences
3
PLANNING
FOR
Bioinformatics
Facilities
by Glen E. Conley, AIA
With the advent of Bioinformatics and Computational Biology, a new model of
medical research facility is emerging—one that stresses the sharing and collection
of digital information as opposed to the traditional, wet services-intensive medical
research lab where processes and experiments are conducted on the bench top.
4
Architecture for the Health Sciences
T
he related but distinct fields of Bioinformatics and
Computational Biology rely on the application of computational tools and modeling to expand the use of
biological data and simulate the interaction and behavior of
biological systems. With the ever-increasing, multiple capabilities of computational data and theoretical analysis, medical research has truly entered the digital age. The iterative
processes used to test and monitor drug interactions or
cell growth are no longer reliant on real time data collection
and analysis and have been shifted into hyper drive by the
seemingly limitless capacity of virtual, digital simulation of
the same processes. The initial phase of testing hypotheses (or hunches) can be accelerated exponentially, without
the time and resource constraints previously experienced
by medical researchers.
To accommodate the computer-based medical research
team, the architect must turn away from the traditional
model of a biology lab and focus on creating an environment that is tailored more toward software engineering
than tissue culture and microscopy. Aside from the obvious need for data ports instead of piped gases, the bioinformatics research team requires workspace that has flexibility in the extreme, to accommodate the diverse variety
of team and individual work activities. The need for balance between the competing requirements for collaboration and quiet concentration, community/team and personal spaces, openness and enclosure provides a challenging
design problem.
Architecture for the Health Sciences
The design program for a bioinformatics-based research facility has one major goal in common with that of a traditional wet
lab facility: to foster informal, unplanned interaction between
the researchers themselves. The sort of redirected thinking
that can result from this type of chance meeting of colleagues
has been found to be at the root of numerous scientific breakthroughs. This desire for synergistic interactions between
researchers has long been understood by research institutions and architects as an important secondary objective in the
design of the research facility. In this regard, the bioinformatics laboratory is no different from the traditional wet lab.
The bioinformatics researcher is likely to be a member of a
team as small as two or as large as 12 or more individuals.
The work itself can be very independent or isolated—focused
on one component of a complex cell structure, reaction or
process. The bioinformatics team may function exactly like
software engineers, writing complex computer program code
intended to be joined together in sequence with the work of
others on the team or in conjunction with another program or
team. The computer program 'architecture' must be understood and adhered to by the group of individual programmers.
Hence the need for team interaction, brainstorming or socializing. This interdependency between otherwise independent
entities places a premium on the ease with which meetings
can happen spontaneously. Meeting or gathering spaces
must be instantly usable, adaptable and available in the first
place. The balance between these types of group meeting
spaces and the need for quiet individual workspaces makes
acoustics an important consideration.
5
> FIGURE 1
If the facility itself is large and will be occupied by multiple, independent teams, then the flexibility to accommodate different group sizes in close proximity becomes
critical to maintain space efficiencies. In this way, the
planning and design parameters parallel those of the
modern day wet lab: a modular, adaptable open plan is
needed to allow for the ebb and flow of team/group size
while continuing to facilitate a sense of community and
connectivity. A team may be organized around a team
leader or principal investigator. The success of the group
may dictate the expansion of team size and territory. The
design of the facility should allow for this. In some ways
the bioinformatics facility program does not differ substantially from that of any progressive, data-centered
workplace or corporate office—a hierarchy of workspaces based on planned group and individual activities,
status, leadership, productivity, circulation, ergonomics,
daylight and views, storage, acoustics, etc.
The bioinformatics research team may be an independent
entity or it may function to a degree as a consultant to
> FIGURE 3
one or more traditional bio-medical research teams–testing and simulating theories, providing visualization and
number crunching for computer models of cells, tissues,
agents, writing software to carry out the data analysis,
etc. required by other researchers. For this reason, the
field of bioinformatics is also influencing the planning and
design of the traditional wet lab facility. The integration of
'number crunchers' into the traditional wet lab may soon
impact the space needs of every new wet lab program.
An example of planning for bioinformatics research can
be seen in Figure 1, the First Floor Plan of the University
at Buffalo (UB) Center of Excellence in Bioinformatics, a
component of the Buffalo Life Sciences Complex (BLSC),
located on the campus of the Roswell Park Cancer
Institute (RPCI). A 56,000 SF computational lab facility
housed on the lower two floors of the UB building, each
of the (2) 28,000 SF floors is entirely dedicated to bioinformatics research. The planning concept employed was
that of the village—a cluster of closed offices centered
around an open area of team workstations and meeting
> FIGURE 2
6
Architecture for the Health Sciences
spaces. Extensive informal and formal conference
spaces are provided along a two-story atrium overlooking a shared courtyard, allowing for connectivity
between the researchers working on the first and second floors. At the ground level, the courtyard meeting
spaces and lounges overlap and spread into a lobby
and cafe shared with the other component of the
BLSC, the RPCI Center for Genetics and Pharmacology,
a 150,000 SF biomedical research facility that is
expected to function in concert with the UB bioinformatics facility (see Figure 2).
The planning concept of a village cluster of offices and
workspaces is intended to house as many as four (4)
small teams, or one (1) large team of approximately 16,
which could, in turn, be a component of a larger team
housed in an adjacent village cluster. Closed offices
vary in size and can also function as team huddle rooms
or quiet work spaces for those without offices. Besides
ordinary support spaces that would be required for any
work place such as break room, kitchenette, rest rooms,
etc., the bioinformatics facility may need to house its
own computer room.
The vast amount of data being analyzed by multiple
teams may make necessary a mainframe cluster/server farm. A facility of this type brings with it a rather
pragmatic set of planning drivers: cooling capacity
and UPS power—each of which can overtax a conventional building's systems. In the case of the UB bioinformatics computer room, the program called for a
5,000 SF raised floor computer room to house the
world's 6th-largest super computer. To plan for future
computer hardware/technology needs is to shoot at a
moving target. The processor server rack/housing is
continually being reduced in size while the computing
power is increasing geometrically—a paradox for
those planning the HVAC infrastructure—a shrinking
computer room with an increasing power density factor. The cooling capacity required for this geometric
increase can be astonishing.
The upper two floors of the UB building will house (traditional, wet) medical research labs, including specialized core labs focused on synthetic chemistry, microarray robotics and a class 1,000 nanotechnology clean
room suite. The UB and Roswell Park Cancer Institute
(RPCI) facilities are connected at each floor level by a
shared meeting space and connecting link. The entire
290,000 SF facility will eventually be connected via 2nd
floor link bridge with the Hauptman Woodward Institute,
an 80,000 SF medical research facility. The 3rd and 4th
floors of UB provide excellent examples with which to
compare the different physical layouts that result from a
bioinformatics program as opposed to a traditional wet
lab program. Each floor is approximately equal in area
Architecture for the Health Sciences
(28,000 SF), see Figure 3 [UB 4th Floor]. This arrangement of spaces is an example of the current conventional wisdom in lab planning—open, flexible lab modules
and alcoves, equipment corridor and support/procedure
spaces comprise the lab zone. Non-lab functions to be
kept out of the lab zone include administration, faculty
offices, break rooms and conference rooms. At two (2)
lab modules per principal investigator, the space allocated for 12 PIs is approximately 1,500 SF per PI. There are
24 lab modules and 20 total offices per floor. A total of
(84) other researchers have space allocated, for a combined total of 104 researchers per 28,000 SF floor plate.
In comparison, the UB 2nd floor bioinformatics facility
allocates space for 31 closed offices of varying size,
which could accommodate up to 15 PIs, plus one (1)
Director, 15 'secondary' team leaders and 70 additional
researchers, for a total of 101 researchers per 28,000 SF
floor plate. The lower number of researchers is attributable to the larger tech/researcher allocation in bioinformatics (approx. 100 SF cubicle vs. 32 SF wet lab tech
desk) and the higher number of group meeting/conference/ lounge spaces.
As demonstrated by this example, space allocation per
PI and per researcher is roughly comparable between
wet labs and bioinformatics labs, so the difference lies
more in what is done with the space as opposed to how
much is allocated. Computer modeling of biological
systems, organisms, agents and interactions appears to
be the next 'must have' in health science and biomedical
research. Research institutions will do well to plan for a
new and different facility type to house this promising
field of research and its unique physical requirements.
About the Author
Glen E. Conley, AIA, is an associate at Francis Cauffman
Foley Hoffmann, Architects Ltd. He has over 18 years of
experience in architectural design, construction documentation, lab planning and project management. Glen
has been responsible for the design, documentation and
construction administration of a wide variety of project
types, including research, healthcare, educational, commercial and manufacturing facilities. His area of specialization is in the planning and design of academic medical research facilities Recent projects include
Biomedical Research Building II (BRB-II) a 385,000 SF
high-rise research laboratory and conference center for
the University of Pennsylvania and the Buffalo Life
Sciences Complex, a 290,000 SF academic medical
research center, which will be jointly occupied by
Roswell Park Cancer Institute, Center for Genetics and
Pharmacology and The University of Buffalo, New York
State Center of Excellence in Bioinformatics.
Glen Conley can be reached at 215.568.8250 ext.237 or
[email protected]
7
Careful Emergency Department Pl
by James T. Crispino, AIA
Smart planning and informed decision-making will help emergency department directors, hospital
administrators, vice presidents of operations, chief executive officers, clinical and service line administrators create an emergency department that operates at peak efficiency, respects the needs and
preferences of patients and families while ultimately increasing market share for the hospital.
Remember your earliest hospital experience as an
adult? It is this first experience that hospitals need to
regard as a defining moment in a family’s life—and
often that experience occurs in the emergency
department. That first encounter created a lasting
impression that determined whether you would
return to that hospital in the future.
Typically, a community hospital will admit 20 to 25
percent, or more, of the patients evaluated in their
emergency department. That group of admissions
accounts for 40 to 60 percent of the hospital’s total
admissions. Clearly, the level of activity at the hospital in general is strongly influenced by the level of
activity in the emergency department.
Emergency department utilization will likely continue
to rise, given that the number of uninsured people
continues to grow, while the general population is
aging. Persons 65 years of age and older use emergency services at a rate three times that of persons
ages 45 to 55.
The reasons for the higher utilization as people age
include lack of insurance coverage, the convenience of going to an emergency department and the
individual’s perception of what constitutes an emergency situation. Often, they arrive at the emergency
department only to be evaluated by a health care
practitioner who determines that the patient’s status is not an emergency and the problem could
have been treated in an urgent care center or physician’s office. These practices affect utilization and
the cost of providing services.
8
The average cost to build an emergency department
is $200 to $250 per square foot. Compare that to
building a primary care or urgent care center that usually can be fit-out in existing space or in a professional office building for $75 to $100 per square foot.
Therefore, it costs three times as much to build an
emergency department that uses more highly trained
staff, more technology and support services.
There are six steps that are essential to understand before undertaking the physical planning process and design of an emergency
department. Taken together, they represent a set of Strategic
Guidelines for the initial phase of emergency department planning.
1. ASSESSMENT: Understand the current policies and procedures of the
hospital, including how a patient is admitted. Admission procedures may vary among hospitals; know your own patterns, bottlenecks and the specific functions that occur in
this department. Know and clearly understand patient
information systems and tracking systems for staff, procedures and equipment, including monitoring and imaging systems and how they affect processing patients
through the emergency department.
Establish trends about your current operations. Build
baseline information on physical and technological
issues that will begin to define problem areas such as
long wait times for beds or CT scans. Make maps and
flow charts of your operations.
Make a connection between the number of beds
used annually and to which individual service categories they are admitted, such as Orthopedic,
Cardiovascular and others.
Architecture for the Health Sciences
lanning Can Increase Market Share
2. COMMUNITY NEED: Study and understand the needs of your catchment
area as they pertain to the use of primary and secondary services. What is the distribution of the catchment
area’s demographics by age and the types of services
each category uses?
Determine your market share.
Determine how the population is changing in your
service area. Consider current programmatic forces
in the emergency department and explore whether
they will grow, shrink or remain the same. Review this
information annually and plan for the changes. Start
with this information and follow the trends for your
hospital in subsequent years.
3. ANALYZE: Specifically examine the number of visits to the emergency
department for the last three years and analyze utilization patterns.
When are your peak times of the day and year? What
shifts are involved during peak times and how can
you plan proactively for those peak utilization times?
4. BENCHMARK & SURVEY: Benchmark other similar institutions and compare your experience to them. Look at 8 to 10 institutions
comparable to yours that provide excellent care and
compare policies and procedures. Try to see where
you are in your own experience and where you are
headed. The goal is to develop an informed and quantifiable set of parameters for developing your emergency department and then decide what appropriate
steps can be taken.
Conduct Patient Satisfaction Surveys for emergency
services. Understand the served communities perspective regarding the hospitals emergency services.
The results can inform operational and physical
changes in the emergency department. Goals for
change can be established in the confluence of
benchmarking and survey activities.
Architecture for the Health Sciences
9
A smaller emergency department can
expect to treat on average 25,000 to
30,000 patients per year. The placement
of key ancillary services such as surgery,
radiology, clinical lab and bed control are
important issues to address. As visits
climb above 30,000 annually, you may
consider planning for imaging services
within the emergency department. As
visits increase to the 40,000 to 50,000
mark annually, locating a radiology room
and CT scanning within the emergency
department may be desirable, reduces
length of stay and is cost justified.
5. PROJECT: Develop projections for emergency department change in your catchment area. Look
at population growth and market share within your catchment area.
Slower growth, one-half to 1 percent growth annually or high growth
rates will influence the rate of change demanded of the emergency
department. Based on experience, if there is a 3 percent growth in population, and you open a new emergency department, you can expect to
see an 8 to 10 percent growth rate in visits during the first year of new
operations because people believe they will receive the best care in the
newest emergency department.
6. CAPACITY: Understand the design capacity of the existing emergency department. On average, an emergency department in a community or regional medical center treats 1,200 to 1,700 patients per year per treatment space. By comparison, trauma, tertiary or teaching hospitals average 1,100 to 1,400
patients per year per treatment space. More patients being treated is a
central issue in the planning and design of the space. If you have 20
treatment spaces and are seeing more than 30,000 visits annually, you
may have a space issue. If you are seeing 25,000 visits annually in those
same 20 spaces, the issues may be operational.
Also consider linking the clinical lab, placing it in close proximity to the emergency
department or installing a tube system
that can transport samples and deliver
information. The latter may be done electronically, which is considered optimal.
At smaller emergency departments, clinical staff may multi-task. Consider crosstraining the emergency department staff
to handle peak times in smaller institutions. Remember, smaller hospitals
admit 25 percent or more of the patients
seen there, constituting 40 to 60 percent
of the hospital’s total admissions.
Collaborative Relationships
It is understood that the hospital must
maintain productive relationships with
physicians in the community, given that
patients are admitted in one of three
ways: through the emergency department, from physicians working in the
hospital, and through physician practices
in the community. Each of these ways
affects the process of assigning beds.
Moving the bed control function into the
emergency department can go a long
way towards getting patients admitted in
a timelier manner while setting up more
collaborative relationships. A balance
must be found between the demands of
the community physicians and the
demands of the emergency department.
Getting Started
An experienced consultant, with expertise in emergency department planning,
can guide you through the process outlined above. The Strategic Emergency
Services Planning phase should take two
10
Architecture for the Health Sciences
to four months to complete. Participants should include
the director, service line administrator, key medical staff
and the operations leader. A steering committee may be
formed for administrative oversight. Representatives of
ancillary and support services will also be involved at specific intervals during the study. A two- to four-month physical planning process that is meaningfully informed by the
needs of the community and the goals of the hospital can
then follow this work.
Often, health care professionals believe they need to
expand and make their emergency departments larger,
however, in many cases larger isn’t the answer. Creating a
new emergency department or upgrading an existing one
is an important consideration that reaps rewards for all parties when careful planning and informed decision precede
the design process.
About the Author
James T. Crispino, AIA, is president and director of planning for
Francis Cauffman Foley Hoffmann, Architects Ltd. Jim studied
architecture and planning at Drexel University in Philadelphia and
received a certificate in Health Facilities Planning from Harvard
University in Boston. He is a member of The Society of College and
University Planners and The American Association of Medical
Colleges.
Jim Crispino can be reached at 215.568.8250 ext. 270 or
[email protected]
© Don Pearse Photographers, Inc.
Architecture for the Health Sciences
Images courtesy of Francis Cauffman Foley Hoffmann, Architects Ltd.
11
EMERGENCY
DEPARTMENTS:
The New Front Door
Beth Leslie Glasser, AIA • Edited version of article originally published in The Academy Journal, a publication of the AIA Academy of Architecture for Health
12
Architecture for the Health Sciences
ith the dramatic rise in emergency department utilization there is an increased focus on
the importance of the ED. According to Modern Healthcare, construction of new emergency centers increased 25% just in a single year in the late 90s. This ‘building boom’ has
continued. Many urban hospitals receive upwards of 45-55% of their admissions through the
ED, and smaller hospitals have seen dramatic increases in their admissions through the ED
as well. As a result, the ED is seen by many as the new “front door” to the hospital — equally important as the lobby and other “high end” areas in creating an overall impression of an
institution, its attitude towards its patients, and the quality of the care offered.
W
Forces of Change
What are the forces that are driving change within the
department? They range from what is, literally, a “micro”
level — infectious diseases like tuberculosis — to the most
“macro” of levels — the federal government and its regulatory and economic controls. For clarity, we have identified
four clusters of issues. These are:
1. Infection Control
2. Escalating Violence
3. Access to Care /Cost Escalation
4. Competition/Regulation/Consumerism
Let’s examine each of these areas and the operational changes
that have been developed in response to each one. Then we will
look at the physical implications.
1. Infection Control
Recent infectious disease concerns (localized outbreaks of
influenza and SARS), coupled with current concerns about the
availability of vaccines, is an issue that many hospitals are struggling with. Being able to identify and contain carriers as quickly
as possible is an important protocol for emergency staff.
The ED, with its large, open waiting room, has been targeted as
an area that could contribute to contamination and the spread
of airborne viruses. In response, many providers are developing
Architecture for the Health Sciences
protocols to identify potential carriers and isolate them from the
general population. Control and containment are the keys to preventing the spread of disease.
2. Escalating Violence
We are all aware of the violence that besets inner-city neighborhoods. In addition to treating the victims of this violence, who
represented 5-1/2% of all ED visits in a 1992 CDC study, hospitals are also dealing with the presence of gang members and
others in the ED’s public areas. In response, many providers
have focused on increasing security to remove the potential for
violence within the ED.
3. Access/Cost
The cost of health care and health insurance has reduced
access to care for many people, as previously discussed.
The major response has been the development of managed care, providing a structure to control access and services provided. Anecdotal evidence from states testing
managed care models suggests that ED visits do decrease
when primary care is available.
The phenomenon of the uninsured patient using the Emergency
Department as their entrance into the health care system is not
new. But with the growth in the size of the uninsured population,
it is the numbers of individuals delaying treatment and relying on
the ED as their primary source of care that is remarkable.
13
4. Competition/Consumerism
Bigger Is Not Better
As managed care continues to grow, the health care industry is
observing a phenomenon we normally do not associate with
hospitals and doctors — price competition.
To address the growing concern about infection control, many
hospitals are exploring ways to provide better separation for
patients and visitors. For many years, hospitals moved
towards more open, flexible treatment cubicles, with curtains
or folding doors between bays. Now we are seeing a reversal
of that trend. In many new departments, all the treatment stations in the emergent care area are fully enclosed. Glass
break-away doors maintain the required visibility, while allowing the space to be fully compliant with current standards for
ventilation and pressurization. It is also worth noting that
good design places all the fittings in the room off of the floor,
allowing more thorough cleaning.
To address the strict cost containment of the managed care
market, and to attract private paying consumers, many
providers are decentralizing ambulatory services and locating them in satellite or off-site locations. Another approach
used to attract private paying patients has been to offer
more focused subspecialty centers and more individual, private care. This segregation of specialties within the emergency department is not only intended to improve the timely delivery of appropriate care, but also to make the patients’
visit to the ED as pleasant as possible.
So what does this have to do with ED design? Good design
addresses these changes. Good planning can, using historical
data, project the types of patients that will be seen and their acuity level. In so doing, adequate space can be provided for each
type of patient (emergent, trauma, pediatric, and so on). Physical
design can play a part in the development of new operational
models for effective triage and treatment of patients. Staff and
patient flow can be analyzed and addressed in the arrangement
of spaces. And changes in technology need to be understood
so that the impact on space (square footage, placement in the
ED) can be incorporated up front in the planning process.
New Concepts in ED Planning and Design
Certain aspects of the planning and layout of the Emergency
Department remain constant: the need for maximum visibility,
the presence of emergent or trauma patients, and the requirement for quick response to a variety of conditions and situations. These concerns are care-driven — accommodating them
supports service that is effective in terms of both quality and
cost. But there are other aspects of ED design that have
changed. Let’s look at these in depth.
14
Humidity and temperature can also be better modulated in a
smaller area, which is important for infection control because it
prevents condensation in ductwork that could provide a breeding ground for bacteria and fungi.
Another related concept is the creation of smaller, more separate waiting areas. One hospital model created separate specialty centers, each with its own waiting area. Fully enclosed rooms
and partly enclosed alcoves separate the main waiting room
into blocks of no more than 100-150 square feet with private
waiting rooms opening off of a larger common area. These private rooms also allow a more intimate setting for doctors to
confer with family members, for children to play without disturbing other families, and for families enduring a long stay to have
some privacy and get some rest.
This will provide a benefit similar to the enclosed treatment
rooms. Achieving the recommended air changes in smaller
room modules will be easier than dealing with the huge volume
of air in a typical large waiting room.
Both of these approaches offer flexibility in isolating patients or
suspected carriers. Because of the large number of enclosed
rooms, it is not necessary to selectively screen individuals or call
attention to their need for isolation in a public area.
Architecture for the Health Sciences
Creating a Secure Environment
There are many options available to planners that address concerns about controlling violence in the ED. The specific location
of the Emergency Department may affect the choices made: its
proximity to the hospital's main security office, to the street, even
to public police stations. The use of certain techniques is often
guided by the preferences of hospital security officers—what's
known to them, what they believe to be most effective.
Administrators and ED staff may have other opinions, guided in
part by the message that they want to send to visitors to the ED.
For example, by obviously placing metal detectors and trafficcontrol bulletproof entrance vestibules at the walk-in entrance, a
hospital may scare off people who are frightened by its fortresslike appearance. The same devices, however, may reassure others. The menu of possibilities includes very high-profile interventions to very subtle operational and design devices. The high-profile items (metal detectors, bulletproof vestibules and triage
enclosures) are easy to incorporate into an ED, but are problematic in terms of enforcement. Who is responsible for removing
guns, knives, and such from individuals who set off the metal
detector? Where are they kept? And how does the security officer or triage nurse evaluate whether an individual is “safe" to be
allowed into the triage station or main waiting room?
Many hospitals are opting to use less aggressive security controls — although no less effective, in many people's view. Undercounter silent alarms and A/V surveillance are found in most hospitals, with links to a central monitoring station. But these devices
can be incorporated in very different ways. One hospital may
choose to combine its audiovisual surveillance with its information desk. The public remains largely unaware of the monitors
behind the counter. Another, by contrast, chooses to locate the
main security office for the entire hospital as a central outpost visible between the walk-in and ambulance entrances to the ED.
Whether a satellite security station is located in the ED itself is a
function of the size and layout of a facility and the location of the
security office relative to the ED.
Unclogging the System
Triage has traditionally been used to evaluate the urgency of a
patient's need for care. In the new model ED, triage is being used
not only for this function but to assign patients to different care
options to “unclog the system” by moving non-urgent patients
out of the emergent care area and into more appropriate (and
less costly) settings. One large hospital near Los Angeles has
developed a large interview and triage area forming a hub, sorting patients to a Walk-In Clinic on one side and the emergent care
area on the other. Assessment of walk-in patients can be accomplished in very small cubicles, in the range of 50-70 square feet.
Assessment may be part of primary care or “fast track” clinics on
or off site, observation units, or specialty modules for pediatrics,
cardiac care, or psychiatric observation and treatment. Zoning of
uses is critical. Good planning places low intensity activities near
the main walk-in entrance and the emergent/urgent care area
directly adjacent to the ambulance entrance. Very distinct zoning
of Express Care and Pediatrics may facilitate moving patients
Architecture for the Health Sciences
through to the most appropriate treatment location in the least
amount of time. If placed in a middle zone, these functions can
'swing' to provide overflow capacity to more critical care areas,
depending upon demand.
The “Fast Track” concept allows a hospital to deal with nonurgent patients in a setting similar to a primary care office. One
CDC survey reported that 55% of visits to hospital emergency
departments were for non-urgent care. By providing only the
basics for diagnostic and treatment of minor illnesses and injury
rather than the highly specialized support for trauma and emergent patients, the hospital can save a great deal of money when
dealing with these patients. Visits can also be charged at lesser
rates, which are more likely to be paid by the patient, or reimbursed by the insurer. It is also worth noting that more and more
centers are referring patients to an Urgent Care Center that is
physically quite distinct from the ED, thus insuring that the center can be run more like a clinic, at a lower cost than the hospital
setting allows. (The issue here, however, is to insure that the
Urgent Care Center has a strong enough relationship to the ED
to avoid the perception that the hospital is “dumping” patients or
has refused treatment. In one prominent case in Pennsylvania, a
large hospital lost millions of dollars in a lawsuit when it sent
patients off-site to a lower cost Urgent Care Center.)
New ED design often incorporates observation or clinical decision units into the plans. This “middle ground” offers a way to
deal with patients whose symptoms may be under control but
require monitoring (asthma or diabetes, for example), or patients
who need to be watched to determine the severity of their injury.
Observation units, like Fast Track areas, offer an opportunity to
provide care in a separately staffed environment specifically
designed for this purpose. These units can save money by
reducing the number of admissions and discharging patients
more quickly, as patients are monitored on an hourly basis with
more frequent physician visits than on a med/surg inpatient unit.
Observation units can be open or enclosed. It is worth noting that
the observation unit should have its own dedicated staff, so that
the area is not simply used as a “dumping ground” for patients
who are then left unattended.
Historically, observation has been classified as 23-hour care. In
some places, observation has been extended to cover up to 72
hours of care. In these cases, the observation unit often serves
as a backup for outpatient surgery or cardiac catheterization units
as well as the ED. Whether it is most appropriate to place such
a unit within the ED or elsewhere in the hospital obviously
depends on the anticipated volumes generated by each area and
local licensing regulations.
If historic data supports sufficient volume, some emergency
departments are providing other specialty areas as well.
Pediatrics specialty areas are fairly common; others that tend to
be seen less often are Psychiatric Observation, Industrial
Medicine, and Chest Pain Units. In all of these cases, the goal is
to provide specially designed areas with trained staff that can
address the specific needs of these populations and move them
out of the trauma and emergent care areas.
15
In the UK, several hospitals have begun to experiment with radically different operational and physical models to address the
phenomenon of an overwhelming emergency patient workload. One idea creates a completely distinct Assessment Unit,
backed up with a large complement of diagnostic areas
(Radiology, Cardiac Cath, Endoscopy, and Lab). This model has
identified an 18-hour length of stay, taking all emergency
patients that cannot be immediately diagnosed and putting
them in an area with the sole mission of diagnosing, and then
either treating, discharging, or admitting on to an appropriate
bed with a care protocol already in place.
A second model takes this one step farther. After analyzing its
length of stay data, one of our hospital clients recognized that
many of its patients are in the hospital for less than three days,
and require relatively quick and urgent treatment. Their model
develops a separate “Acute Take” area, effectively functioning as
an emergency hospital in concert with the Accident and
Emergency Department and the required Diagnostic and
Treatment functions. Only chronic patients and elective patients
move on to the specialty wards elsewhere in the hospital, thus
“protecting” the elective workload from being overtaken by emergency demands.
Both of these models are in their infancy, but suggest ways that
the ED and associated activities may, in fact, continue to grow and
change into totally new forms to deal with the pressures of modern medicine. The lesson here is to think creatively about what
really constitutes an “Emergency Department.”
Technology in Action
With the increasing decentralization of services, there is a parallel movement to deliver services to the patient (rather than
vice versa). Changes in technology and the development of
systems that manage and track diagnostic and treatment procedures make it possible to work remotely or from satellite
locations rather than having to physically deliver the patient or
specimen to a service site. These changes in technology have
affected the way the new ED deals with lab work, pharmacy
orders, and diagnostic procedures.
These systems can be used to support the lab, pharmacy, and
radiology to move samples, medications, and films back and
forth between the ED and the main department. Within the ED,
one need only provide the required station for the carrier or
vehicle to arrive, be unloaded, and dispatched. These materials
handling systems allow the ED to make use of support
resources at a distance without the need to provide full staff
coverage or duplicate equipment in a satellite location. Some
opponents of satellites also argue that by using the main
department, there is better quality control.
Other high-tech support systems are available for
specific applications:
Hand held diagnostics will allow trained personnel to perform a
variety of routine tests without the need to return to a workstation.
Computerized dispensing of medication provides a secure, reliable, and accountable system for delivering either routine or stat
meds on site within the ED. Software allows the hospital to
charge for every withdrawal made from the system; the pharmacy can also keep track of utilization and stocking. It is important to
note that this does not eliminate the need for a meds area, as certain items are typically not kept in the computerized dispensing
unit. We have observed several hospitals where it was assumed
that the unit would eliminate the meds area altogether, and these
facilities have had to retrofit a space to address the overflow of
meds support.
Robot servers are also being developed. These robots will be able
to be programmed to travel to a destination and deliver meds or
supplies as instructed. Like AGVs, robots move by radio instructions and have sensors. Unlike AGVs, robots are designed to
move in the same corridors as people. In the ED, robots offer a
way for a nurse to receive non-stock meds from the pharmacy
without having to leave the department—particularly significant
on an understaffed shift.
Picture Archiving and Communication Systems (PACS) is rapidly
gaining acceptance as a replacement for conventional films. With
PACS, an ED can be equipped with its own equipment and
In many older hospitals, for example, the laboratory is often found
near the Emergency Department. This, obviously, is in response
to the need for frequent ‘stat’ diagnostics, and the large volume
of tests generated in the ED. With improvements in telecommunications (phone and computer links), newer EDs now have satellite laboratories, pharmacies, and radiology suites capable of
doing many of the most common tests and filling most drug
orders. However, the need to duplicate equipment and trained
staff has been a problem in many hospitals. These satellites also
pose the problem of potential “structural idle time” — paying a
trained specialist to sit around while waiting for the next test or
order to arrive. For these reasons, many facilities have begun to
rely on various materials handling mechanisms such as computer controlled Pneumatic Tube Systems (PTS), Automated Guided
Vehicles (AGVs), and Automated Box Conveyors (ABCs).
16
Architectural Health Services
trained technologists and the image can
be immediately dispatched to a radiologist in the main department or even offsite. Although the cost of the ED radiology suite is still incurred, the need to
have an on-call radiologist available within the department or to carry films to the
radiologist has been eliminated, thus
saving manpower and time.
Appropriate Care
Delivered in the Most
Economical Setting
Ultimately, the goal of the Emergency
Department is to efficiently deliver care
to patients in need. In today's world of
escalating health care costs, increased
management of care by third parties,
and changing patient needs, we would
like to suggest a motto that restates the
mission of today’s ED, “Appropriate
Care delivered in the most Economical
Setting.” Response remains an
unchanged mandate; needs must be
addressed without delay. Thinking back
on some of the evolving ideas about
specialty emergency care and innovative models for assessment, it is clear
that the “one size [and type!] fits all” ED
is no longer viable. Quality of care is
paramount, both in terms of the
patients' well-being and the reputation
of the hospital. And efficiency of care, in
our increasingly cost-conscious environment, may very well dictate
whether the already overburdened ED
is able to stay afloat financially and continue its important role as the hospital’s
new front door.
About the Author
Beth Leslie Glasser, AIA, is director, health facilities
planning at Francis Cauffman Foley Hoffmann,
Architects Ltd. Beth is a specialist in the programming, planning and design of health facilities, with
over 20 years of architectural experience involved
in all phases of health facility design and construction. She has a special interest in academic medical centers, women’s and children’s facilities, and
emergency patient management. Beth has headed up strategic planning and programming efforts
for four major hospital projects in the UK, including
major teaching hospitals in Edinburgh and
London. Experience in urban design and planning
outside of the health care field contributes to her
abilities in master planning large-scale medical
centers and campuses.
Beth Glasser can be reached at 410.732.3400 ext.
23 or [email protected]
Architecture for the Health Sciences
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17
Case Study:
Consolidating Multiple
Laboratories
by Edgar G. Bermudez, RA
Technology, new regulations, multi-disciplinary testing and cost are
issues affecting the design of new laboratory facilities. Remaining
competitive requires an understanding of the issues and the trends
affecting the design of such facilities. This article addresses these
concerns and provides the three keys to successfully designing laboratories that can adapt to changing needs.
18
Architecture for the Health Sciences
In 1996, the two largest hospitals
within Harrisburg, PolyClinic and
Harrisburg Hospital, merged to
form the PinnacleHealth System
(PHS). The System then expanded
with the addition of two suburban
Harrisburg hospitals, Seidle and
Community General Osteopathic
Hospital (CGOH).
Issues Affecting
Planning & Design
In 1997, the System consolidated
the majority of inpatient services
at Harrisburg Hospital with CGOH,
retaining limited Med-Surgical and
ICU bed space. Outpatient services were consolidated at PolyClinic
and Seidle, and then expanded in
2000 as the Fredrickson outpatient
center across the Susquehanna
R i v e r. T h e c u r r e n t C l i n i c a l
La b o r a t o r y C o n s o l i d a t i o n a t
Harrisburg Hospital will eliminate
the remaining duplication of laboratory services.
New regulations permit decentralized planning, making it possible to
locate routine laboratory functions
remotely from the hospital campus.
Testing in support of the surgical
suite, the emergency room and critical care units remains in the hospital
but even those functions no longer
need to be at grade level or near the
emergency department and operating rooms due to improvements in
transport and testing technology.
The clinical laboratory is responsible
for processing all tests involving the
analysis of body fluids and tissues to
facilitate clinical decision-making.
Within the lab, multi-disciplinary
testing equipment is eliminating
separations between lab sections
and creating the opportunity to
design in the Open Lab Concept.
Many entities have jurisdiction over
the operations of the clinical lab,
among them OSHA, NFPA 99, local
building codes and regulations,
and the College of American
Pathologists. Besides regulatory
compliance, the design needs to
integrate the lab’s operational
style, flexibility of the design to
adapt to changing demands and
technology, quality control, and
worker safety and comfort.
For the mid-Atlantic region, benchmarking cost data (2002) for shell,
fit-out and fixed equipment costs,
OPTION C: THIRD FLOOR PLAN
Images courtesy of Mortland
Planning & Design, Inc.
www.mortlanddesign.com
Architecture for the Health Sciences
19
suggests a range of $125 to $225
per square foot in an office building versus $220 to $325 per
square foot in an institutional
building. Moveable metal casework may range between $235
and $350 per linear foot. Because
renovations are dependent on
many particular conditions, those
costs were not profiled.
Laboratories are high- energy
users mostly because they
exhaust 100% of the air they use
at 8-10 changes/hour. The OSHA
minimum is 4. Energy costs for
labs range between $8/10 per
square foot as compared to $2/3
for an office building.
20
Trends Affecting
Planning & Design (1)
Reimbursement and regulatory
changes, such as the prospective
payment system (1980), made labs
cost centers rather than profit centers. Additionally, Medicare legislation and negotiated reimbursement
rates put pressure on labs for rapid,
accurate results.
The Clinical Laboratory
Improvements Amendment (1998)
mandated quality and personnel
standards and removed an obstacle
to decentralization by eliminating
the need to license in-hospital and
off-site laboratories separately.
Shifting demographics, from inpatient to outpatient care, caused
outpatient testing to move to single practitioners and commercial
labs able to deliver at lower costs.
Hospitals are competing by moving testing to the point-of-care
(POC) system, which is consistent
with patient-centered care, and by
improving speed and quality by
the use of new technology.
Staff demographics indicate that
clinical technicians tend to be
older and have a high attrition
rate. In addition, hospitals seldom
offer training. Staff satisfaction
and retention are critical issues.
Architecture for the Health Sciences
New technology has affected the physical
capacity and functional design of laboratories to
accommodate biosensors, molecular biology,
portable and movable technology, random
access analyzers, minimal blood analysis, black
box technology with internal calibration and
quality control, and robotics.
Last but not least, hospital networks and
alliances have changed the way services are
delivered.
The laboratory of the future will be designed differently. New operational demands, technology
and changing hospital policies and procedures
are affecting current design and will continue to
shape new design parameters.
Planning and Designing the
Pinnacle Clinical Laboratory
• Determine the needs of the Laboratory in the
context of the long-term needs of the System.
• Establish the desired level of quality and
appropriate budget and then manage the
process to remain within requirements.
• Execute a building design capable of maximizing the use of this premium location.
Determining the Needs
Establishing Pinnacle’s physical needs depended on understanding their market and gaining
knowledge of jurisdictional requirements and
available testing methodologies and equipment.
Using prior planning information, PHS had determined the required capacity independent of
location or the degree of technological sophistication required to support those needs.
Intensive programming with the users yielded a
detailed space program, diagrammatic plans
and a detailed listing of existing and new equipment. These parameters became the foundation
for the development of locational options and
enabled PHS to select one of the on-campus
schemes for design development.
M E C H A N I C A L & E L E C T R I C A L C O N S U LT I N G E N G I N E E R S
PLUMBING
FIRE PROTECTION
MEDICAL GASES & VACUUM
HEATING, VENTILATING & AIR CONDITIONING
INTERIOR & EXTERIOR LIGHTING
The initial budget was prepared using the program area, our benchmarking studies and the
construction manager’s local costing. This information was used by administration to quickly
evaluate options and adjust scope. To facilitate
Board approval, the design team prepared multiple presentations illustrating the appearance of
the building at the end of this and future building phases.
POWER GENERATION & DISTRIBUTION
FIRE ALARM & SECURITY SYSTEMS
INFORMATION TECHNOLOGY SYSTEMS
INFRASTRUCTURE STUDIES
SYSTEMS ASSESSMENT & MASTER PLANNING
Barton Associates, Inc.
Consulting Engineers
Susquehanna Commerce Center
North Building
221 West Philadelphia Street
York, PA 17404
717.845.7654
www.ba-inc.com
CONTROLS & COMMISSIONING
We Make Buildings Work
Architecture for the Health Sciences
21
Establishing the Level
of Quality
The stated goal of PHS was to
develop a new lab that would
remain competitive over an expected 20-year life while meeting these
criteria:
• Remaining flexible
• Maintaining quality control
• Ensuring worker safety and comfort
• Meeting regulatory compliance
standards
• Having adequate capacity to serve
networks
Designing a technologically
advanced facility capable of adapting to changing testing needs
meant installing robotic lines capable of accepting existing and new
analyzers.
Architecture and engineering systems were designed to meet laboratory safety standards as mandated
by numerous codes that require
periodic review by accrediting
organizations.
campus, it was critical that the
building anticipated in its architecture and engineering systems vertical growth for future hospital uses,
including bed units. PHS increased
the budget to include these future
premiums.
analyzers for improved quality control, safety and staff comfort. The
building is a flexible structure capable of expanding vertically in multiple building phases for virtually any
health care related use without
compromising built work.
Executing the Design
Previous structures include disparate architectural styles. The new
design unifies these structures and
provides a signature building at a
very prominent urban intersection.
Getting the building program to fit
the envelope and budget required
an understanding of codes and regulations, functional relationships,
and the expectations of the decision
makers. Multiple options, including
multi-level labs, were developed
and evaluated in terms of function
and cost.
The new lab is contiguous to the
existing main hospital and consolidates the function of remote existing labs at the main campus. The
new lab facility also features direct
access by surgeons and pathologists to a new Frozen Section Lab
accessible to both surgeon and
pathologist in a sterile environment.
Laboratory technicians are scarce,
relatively elderly and have a high
attrition rate. Therefore, attractive
and comfortable surroundings were
required to attract staff and foster
staff retention.
Adopting the Open Lab Concept
made possible by multi-disciplinary testing equipment eliminates
traditional departmental separations, except as mandated by
code or safety, or as required by
convenience.
Because the laboratory site is the
last significant piece of land on
The design includes two robotic
lines integrating new and existing
With the design of the new facility,
PinnacleHealth is positioned at the
forefront of clinical laboratory
design, poised to take advantage of
coming trends including:
• Point-of-care testing
• Changing staff roles focusing on
quality control and cost containment
• A focus on recapturing processing of out-patient tests
• Organization of labs around turnaround times in a decentralized
environment
The facility, scheduled to open in
the summer 2005, has received
public praise from the community
and the Mayor of Harrisburg for its
innovative design.
(1) Superior Consultant Company, Inc 2001
About the Author
Edgar G. Bermudez, RA, is a senior project
manager at Francis Cauffman Foley
Hoffmann, Architects Ltd. He is a registered
architect with over 30 years of experience in
the planning, design and management of a
variety of building types, including 20 years’
contribution to healthcare projects from programming through construction administration. He is an accomplished team builder
and manager of complex healthcare projects. Edgar manages the work progression
to ensure the timely presentation and submittal of documents that are coordinated,
accurate, properly detailed, and represent a
design that meets the quality expectations
and budget requirements.
Edgar Bermudez can be reached at
215.568.8250 or [email protected]
22
Architecture for the Health Sciences
Architecture for the Health Sciences
23
STATE
UNIVERSITY
OF NEW YORK
AT STONY BROOK
Case Study:
Doing A Lot With A Little
by Thom L. Lehman, AIA
24
Architecture for the Health Sciences
PROJECT DESCRIPTION
The School of Medicine at SUNY
Stony Brook was interested in
upgrading laboratory modules at
their Life Sciences Campus. SUNY
recognized that in order to attract
top-tier researchers, they needed
to provide quality laboratory space
with flexibility for future change,
reliable services designed for
growth and modern amenities like
other great research institutions.
The first space considered for renovation was a pharmacology laboratory to accommodate a newly
hired researcher moving his laboratory from another university. The
entire 25,000 GSF floor plate was
planned to capture organizational
efficiencies and is scheduled to be
constructed in three phases.
Phase I includes the renovation of
5,500 SF of a 10,000 SF open pharmacology laboratory, including
common procedure rooms that will
serve subsequent phases. Phase II
is for the construction of the
administrative and conference
functions
to
support
the
Pharmacology
Department.
Phase III is for the balance of the
open pharmacology laboratories.
The keys to the success of this
project were:
Architecture for the Health Sciences
• Identifying existing spatial and
infrastructure inefficiencies
• Providing centralized, shared
administrative and lab support
functions
• Maximizing available natural light
MAXIMIZING EFFICIENCY
Giving SUNY the best quality laboratory space in a building with limited
infrastructure and a challenging
building geometry required a thorough analysis of the existing building conditions and creative planning
to maximize usable floor area.
• SUNY began the process by
acknowledging the philosophical
shift in research from the era
w h e n t h e o r i g i n a l research
towers were built.
The original laboratory
plans focused t h e
r e s e a r c h e r s
inward on research
and encouraged little
contact between laboratory groups and
other researchers.
New plans began with
the understanding
that research requires
social interaction.
• The design team conducted an
assessment of the existing space
and building infrastructure in
order to develop a sound basis
for a new design.
• Site observation revealed that the
agglomeration of laboratory renovations had created a warren of
small, unsafe and inefficient laboratory and support spaces.
Researchers conscripted many
spaces for functions that they
were never designed to accommodate. SUNY quickly determined that a gut renovation was
required.
• Analysis of the original architectural plan revealed spatial inefficiencies caused by a rigid geometric plan—a cylindrical core in
a square plan with major circulation on the diagonals that cut
across the square.
• The design team interviewed
future occupants of the laboratory to establish benchmarks for
the new design, including functional requirements, bench services and infrastructure demands.
This led to the development of
three model plans with open laboratories, administration and conference functions organized on
one floor to maximize efficiencies
and provide the right environment
for researcher interaction.
SUNY Comment: “…[T]he programming and planning for 40,000 SF of
laboratories and offices for the
School of Medicine and the project
finished on time and on budget...
vastly improving the quality of our
laboratories at Stony Brook University
25
and enabling us to attract top-notch
researchers with the new facilities.”
Glen Itzkowitz, Director, Biomedical
Services, SUNY at Stony Brook
CENTRALLY LOCATED
SHARED SERVICES
The building program capitalized
on providing shared administrative
and laboratory support services in
a central location to encourage
efficient circulation and movement of supplies.
• The interviews helped establish program requirements for the
whole floor, including the
amount of administrative/conference area and the ratio of
shared services to laboratory
benches.
• Consolidating shared services
reduced construction costs by
ganging and shortening utility
runs and made more space
available for laboratory benches, flexible procedure rooms
a n d c o n f e r e n c e / b r e a k- o u t
areas where researchers could
interact.
• Shared and specialized spaces that
cost more to build, like the cold
rooms, glassware wash and
dark room, were located as
close to the central core as possible to allow a limited number
of rooms to be shared with the
most people.
• The shared laboratory functions are
located at or near the diagonal
circulation, allowing for the
most efficient movement from
laboratory to support space and
providing easy access to utility
chases in the building core.
• Supplies can easily be moved from
the elevator core to storage
located near the core. Gas tank
storage is located at the main
entrance to each laboratory to
limit the length of travel from the
elevator and interruption of laboratory activities.
26
Architecture for the Health Sciences
MAKING THE MOST
OF AVAILABLE
NATURAL LIGHT
The design focused on sharing
available natural light with as many
individual researchers as possible,
making use of open laboratory
planning, open-shelved casework
and vision panels in office doors to
bring light to the interior.
• The hallmark of contemporary
laboratories is the abundance of
natural light. However, SUNY’s
existing building has only 16
windows on each floor!—four
windows at 13’x12’ on the axes
of the building and the rest oval
windows at 3’x9’.
• The open laboratories were
organized to allow the maximum
amount of light from the large
windows to penetrate to the
center of the laboratory. The
office doors were specified with
vision panels to allow shared
light into the laboratory, and the
furniture was specified with
open shelves.
• The affect of light in the interior
is a much-needed relief from the
enclosed, darker spaces of the
existing facilities. Researchers
can now work in a space filled
with light and a view to the outdoors.
About the Author
Thomas L. Lehman, AIA, is an associate at
Francis Cauffman Foley Hoffmann,
Architects Ltd. He has over 13 years of
experience as a project architect and a
project manager for large-scale commercial projects. Thom has been responsible
for all phases of a project—from design
through construction administration. He
demonstrates a keen understanding of the
complete building process, a responsiveness to client's interests and the ability to
work well with others at every stage of a
project.
Thom Lehman can be reached at
215.568.8250 ext. 342 or
[email protected]
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