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. Office Locations 2120 Arch Street Philadelphia, PA 19103 215-568-8250 215-568-2639 Fax The Crown Building, Suite 201 304 S. Franklin Street Syracuse, NY 13202 315-423-0463 315-423-9830 Fax The Can Company Signature Building, Suite 402 2400 Boston Street Baltimore, MD 21224 410-732-3400 410-732-7878 Fax www.fcfh-did.com Architecture for the Health Sciences is published by Innovative Publishing Ink! 10629 Henning Way, Suite 8 Louisville, KY 40241 502.423.7272 or 866.423.7523 Innovative Publishing Ink! specializes in creating corporate magazines for businesses. Please direct all inquires to Aran Jackson, [email protected]. www.ipipublishing.com 2 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 Inspire Your Clients Providing Flagship Publications for Architects and General Contractors for over 10 years. To find out how your company can have its own Flagship Publication, contact Aran Jackson directly at 866.423.7523 (toll free) or visit us at www.ipipublishing.com. [email protected] 10629 Henning Way, Ste. 8 • Louisville, KY 40241 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] To advertise in future issues of ARCHITECTURE for the HEALTH SCIENCES, please contact Bryan Zehnder at 502.423.7272 or [email protected]. www.ipipublishing.com Architecture for the Health Sciences 27 Francis Cauffmann Foley Hoffmann, Architects Ltd. 2120 Arch Street Philadelphia, PA 19103 PRESORTED STANDARD U.S. POSTAGE PAID PONTIAC, IL PERMIT NO. 592