New construction allows more opportunity for an aesthetically pleasing environment and greater ceiling heights in the MRI suite in Grady Memorial Hospital, Atlanta.

As the latest medical technology evolves every 5 to 6 years, hospitals and health care facilities must constantly vie to keep their existing buildings up-to-date. In fact, medical equipment becomes obsolete every 10 years or so, forcing hospitals to consider two options: retrofitting current facilities to accommodate new equipment or building new. Surprisingly, the price tags for renovating and building new are not that far apart.

Various benefits and drawbacks should be weighed for both options. Not only do we look for cost-effective construction; continuation of operational processes and settings that are conducive to healing also contribute to the value.

EXISTING STRUCTURES, NEW LOOK

In nine of 10 cases, real estate is just not available to build new or expand, which is actually a bigger problem than attaining funding. Because these units are often positioned close to emergency centers and other high-tech areas, they are landlocked, thus limiting internal expansion capabilities. Yet, in 90% of remodeling projects, issues arise with current room dimensions. And it is not only a problem when retrofitting a building that has reached the benchmark life expectancy, typically 50 or 75 years.

Until the mid 1980s, the standard floor-to-floor height in hospitals was less than 12 feet. The technology associated with today’s imaging equipment, compared with what was used 10 to 15 years ago, requires more support infrastructure. The standard height equipment needs in order to work in a room is usually 9′ 6″ high. In these cases, soffits taking up 12 to 18 inches are used to conceal HVAC, sprinkler systems, and the supporting electrical infrastructure for the actual imaging equipment. While functionally this is adequate, aesthetics are compromised with these lowered ceilings. A metal channel grid or truss system above the ceiling is also needed to support equipment that hangs down, such as fluoroscopy machines.

Size requirements do not change with digital mammography, but equipment needs do.

The size of the actual equipment being used is not growing, but the amount of equipment required in some rooms is increasing. At one point, the standard for viewing x-rays was film illuminators on the wall; now there are individual reading stations with banks of computer monitors that can require more space. The imaging technology associated with fluoroscopy also requires more physical space for anesthesia, power, and oxygen requirements, as well as additional personnel.

Rooms that have been built in the past 20 years for standard radiology and chest x-rays, the mainstay for imaging, may be retrofitted for digital imaging with minimal remodeling. These rooms do not usually need greater requirements than they did 10 years ago. However, institutions with picture archiving and communications systems (PACS) require larger rooms for viewing images on banks of computer screens as well as a room for housing computer servers. Some hospitals utilize what was once the records room for this, since digital images do not take up the much-needed space.

One current HDR project that posed a unique problem and solution is the renovation of the St. Francis Hospital Cardiac Care Unit in Milwaukee, Wis. The hospital desired to upgrade its interventional departments and become more competitive with other cardiology facilities in the area. It was more economical to remodel and replace this unit than to upgrade the entire radiology department.

Ceiling-mounted equipment requires an extensive metal truss system above the ceiling.

Like many hospitals built in the 1980s, the use of post-tension cables stretched in the floor slabs adds expense and difficulty in renovation. Since the control box for imaging tables is placed in the floor, the floor slab must be x-rayed to locate the exact location of the stretched cables. Very carefully, the floor is cut around the cables and the new box housing the control components and wiring is dropped in. A 12-inch depressed area in the floor may be needed for portions of the equipment. Soffits were also utilized in this project, and since the exact location of the control box in the floor was not yet known, it became necessary to keep the location of the four fixed perimeter walls flexible. Just prior to construction, if the control box needs to be moved more than two feet from the anticipated location, the unique design allows for placement of the walls to adjust accordingly.

When complete in December 2004, the 11,000 net-sq-ft (the entire unit is 16,000 gross square feet) renovation of the Cardiac Care Unit at St. Francis will house two new catheterization laboratories, one relocated catheterization laboratory, and one new electrophysiology room. The total cost of construction for this 8-month-long project is $2,200,000. At $200 a square foot, it is slightly lower than that of new construction.

STARTING FRESH

There is a trend to build new state-of-the-art buildings for diagnostics, rather than retrofitting for several reasons. If fundingand spaceis available, having an aesthetically pleasing, natural light-filled hospital that promotes healing is ideal. A new image associated with a new building brings the potential for philanthropy and naming rights to the facility. Specifically for the imaging department, floor-to-floor heights could be designed at 14 to 15 feet, providing the optimal two to three feet of interstitial space with a clean, straight ceiling. Despite the most inventive designs, there is only so much that can be done with an old footplate.

Another major benefit for new construction is that a project can easily be phased, so it does not interfere with the existing unit being replaced, which is a difficulty with remodeling in place. Barriers need to be constructed, but, nonetheless, construction and service traffic often have to share the same passageways. Construction can also contaminate the existing laboratory, and use of negative pressure is needed to keep contaminants in place and out of the laboratory, which the administration does not have the luxury of shutting down while renovation is under way. A rented or leased mobile unit may be brought in to move procedures out of the construction zone. But these units are expensive and must be added to the cost of retrofitting the department.

When all costs are factored in, building a new expansion for imaging departments is typically more economical. Commission of a new imaging department can be completely transitioned in a few days, without ever having to shut down. As a natural progression, the former laboratory may be refurbished for support functions, such as locker rooms or patient waiting rooms. In a new facility, the structure would be designed with the depressions, cable boxes, and support equipment for placement in the floor.

An HDR new expansion project for Wisconsin Heart Hospital located in Wauwatosa, Wis, a suburb of Milwaukee, scored high marks for its expeditious construction time frame, which was able to be fast-tracked. The 125,000-sq-ft facility, which contains five catheterization laboratories, two operating rooms, including shell space for one additional of each, a full-service emergency department, and CT/RF/MRI capabilities, was completed within a 16-month time frame. This was achieved at a construction cost per square foot of $230, only slightly higher than that of a retrofit.

The advent of teleradiology and PACS, through which digital imaging can be viewed remotely, changes processes dramatically in the future. It is possible for radiologists to read uploaded images for an entire enterprise at a core location outfitted with the large, extremely dark viewing rooms that are optimal. In such a configuration, all buildings in a health system would not require an updated viewing room, freeing up space to expand the imaging rooms and laboratories.

Remote reading is part of the plan with the St. Francis project. While the reading room is located within the imaging suite, the large computer servers are remoteon the lower level of the hospital. It is not necessary to build a computer room within the department, since the hospital’s mainframe server room in the lower level was used.

When there is opportunity to build new, it is generally better to start fresh. However, each case is unique. Complex factors need to be weighed regarding real estate available, landlocked units, contamination, processes disrupted or contaminated, and assessable resources. When all the numbers are crunched, it sometimes comes as a surprise that the costs of renovating and new construction are closer than you might imagine.

Terence Houk, AIA, is senior designer, HDR Architecture, Chicago.