Incoporating Innovation

Darrell Carlson, AIA, Vice President HGA, Inc.,Minneapolis, Minnesota
Darrell Carlson, AIA, Vice President HGA, Inc.,Minneapolis, Minnesota
Over the past decade, as the trend continues to grow for noninvasive and minimally invasive catherization treatments, as well as for more aggressive invasive treatments, so does the quest for modern, well-equipped and profitable catheterization laboratories. Because cardiology and catheterization procedures are generally a profitable market segment, healthcare organizations are competing to increase their sphere of influence in order to generate more dollars. In 2001, the American Heart Association and the American College of Cardiology developed The Stages of Heart Failure. These stages help patients understand that heart failure is often a progressive condition that can worsen over time, according to WebMD Health.com in collaboration with the Cleveland Clinic. A table in the study outlines a progression of treatments that increase incrementally at each stage of the disease. At the same time, procedural advancements and emerging technologies are making dramatic changes in treatment processes. With information more readily available and more people recognizing symptoms prior to a heart attack, there is a greater chance that less invasive techniques will achieve a positive outcome. It’s good news for patients who once may have required aggressive treatment such as bypass surgery, possibly requiring a 10-day hospitalization and a long recovery. Today, a diagnostic angiogram and/or angioplasty procedure may take the place of surgery, and many of these patients can be discharged home the same day of their procedure. At the same time, a developing trend is for more aggressive treatments to be performed in catheterization laboratories. Customarily situated adjacent to an operating room (OR), catheterization laboratories are being designed as standalone entities and in fact, in an increasing number of cases, plans to build new ORs are being scratched and replaced with plans to add more invasive cardiology laboratories or to update existing laboratories. More than ever, these standalone laboratories are able to perform a greater number of invasive cardiovascular therapies, including, in some cases, complicated surgical procedures. As a result, some catheterization laboratories are being equipped with the same mechanical and sterility levels as an OR. This is having a profound impact on the way catheterization laboratories are designed. First, as a result of the shift to less invasive treatments, additional diagnostic equipment is required, including large computed tomography (CT) scanners and magnetic resonance imaging (MRI) equipment. More equipment demands more overall space and more floor-to-floor height for support infrastructure. Equipment is heavier and more sensitive, often requiring upgrades in structural systems. Higher-grade HVAC systems are necessary to keep the air clean and to maintain temperatures for critical surgical procedures. The following are solutions to four common retrofit challenges, as experienced by HGA, Inc., a full-service architectural firm headquartered in Minneapolis, Minnesota. One example is a case study of St. Cloud Hospital, a regional medical center serving central Minnesota that recently added four state-of-the-art catheterization laboratories. Height issues Individual catheterization laboratory units are larger today than even five years ago. There is a need for a higher floor-to-floor height than formerly deemed acceptable. While new facilities usually have no objection to adding equipment for the latest technologies, retrofits of existing facilities which are more prevalent may require more innovative solutions. Additional scanning equipment, as well as better air systems, are causing a shortage of both usable floor square footage and space for services above the ceiling. Huge, modern equipment such as articulating C-arms, booms with monitors and other systems, have upped the ante on higher ceiling heights a minimum of 9 ft. 6 in. clearance is required for ceiling-mounted equipment. In fact, many newer ORs are being built with 12 ft. clearance ceiling heights which is very difficult to attain in older hospitals. Older buildings, which typically have only 11 ft. 6 in. or 12 ft. floor-to-floor heights, do not leave sufficient space for the medical instruments and gas columns, or the space required for ductwork and lighting. HVAC challenges Many hospital decision-makers are beginning to request the same precision mechanical equipment for air systems in a catheterization laboratory that are provided in an OR. Features may include laminar flow air systems, HEPA-filtered spaces, and spaces that require a high number of air changes per hour, usually associated with surgical suites. Ductwork for these air-handling units may require a total of 16-17 ft. of floor-to-floor height. One method to accommodate higher ceilings for the mechanical system is to run conduits through soffits at the sides of the room. Another solution is to convert two vertically connecting floors of a building into one floor of useful space. A third means to overcome the lack of height needed for an HVAC system or equipment is to build on the top floor of a building and expand the roof up a few feet, a solution that was employed at St. Cloud Hospital, part of the CentraCare Health System. Inadequate space was left for mechanical systems infrastructure at the St. Cloud facility. The area adjacent to the existing Heart Center, which was converted into catheterization laboratories, was partially an already-existing narrow patient area and partially the roof of the radiology department below. The floor-to-floor height of the existing patient area was 12 ft. 4 in., with a 2 ft. concrete structure. However, the manufacturer of the ceiling-suspended equipment required 9 ft. 6 in. clearance for ceiling height, leaving only 10 in. for services. The solution was to build a new roof structure 5 ft. above the existing roof, creating an interstitial space where duct runs could be accommodated. In addition, this plan provided the new catheterization laboratory areas outside the existing structure with a high floor-to-roof dimension to accommodate the required services for these additional spaces. A steel structure was selected for the addition because it is much lighter than concrete and much easier to install into an existing condition. Steel sections were also used to reinforce and stiffen the existing concrete structure to compensate for the additional imposed loads. Structural issues and deflection Manufacturers of this type of precision medical equipment commonly require that the substructure and ceiling upon which their equipment is mounted be highly stable and deflect no more than 1/16 of an inch. While an existing concrete structure has little likelihood of movement from deflection, the downside to lighter-weight steel roof construction is deflection, which is movement caused by the exertion of pressure from exterior loads such as snow, rainwater and so forth. Steel construction may need some creative design to meet the manufacturers’ requirements. At St. Cloud, an innovative solution was designed for two catheterization laboratories that were built in the section of the building constructed of steel. Because steel has a natural pliability, and exterior loads can cause significant deflection in a roof structure, the equipment could not be connected to the same structure as that supporting the roof. To overcome this, planners on the St. Cloud project built a separate steel substructure to support the equipment below the main steel roof structure. In a third location, several 30 ft. long by 24 in. deep beams were inched into place through two man doors of a mechanical penthouse and lifted into place 2.5 in. below the roof structure. By separating the two structures, the upper roof structure was allowed to deflect, while providing structure stability in the area that housed sensitive medical equipment. Flexible planning A good healthcare facility designer understands that hospitals want the very latest equipment and sometimes need the ability to specify it just eight weeks before installation. Conventional planning and design, however, must be completed at least one year in advance. To provide the greatest amount of flexibility, experienced planners can work with the specifications of several equipment manufacturers the hospital is considering, planning a sort of universal laboratory, and then quickly making small modifications in the final stages of design to accommodate particular pieces of equipment. This permits better bidding leverage and minimizes costly change-orders. Into the future As the need for catherization procedures rises on both ends of the spectrum from minimally invasive to more invasive procedures retrofitting catheterization laboratories must incorporate creative design solutions. To remain competitive, healthcare organizations need to continue their quest to incorporate emerging technologies with innovative planning. Darrell Carlson, a vice president and registered architect with HGA, Inc., has over 20 years of experience in healthcare, specializing in the planning and delivery of surgical centers, heart centers, community hospitals and specialty clinics. Mr. Carlson can be reached at 612.758.4519 or via email: dcarlson@hga.com. For more information, visit www.hga.com