The only large hospital designed to that standard and operating by 2000 was San Bernardino County's Arrowhead Regional Medical Center, designed by Bobrow/Thomas & Associates, executive and design architects, in association with Perkins & Will.
In considering the structural system for a facility devoted to inpatient care, it is important to select a column grid that will accommodate the narrow dimension of the patient room. A 30-foot (10-meter) square module will typically allow two patient rooms between column lines. For some rooms (labor/ delivery/ recovery rooms, for example) a slightly larger module may be better, dictating this grid throughout the building. Alternatively, such rooms can be oriented differently, with the long dimension against the outside wall.
The building structure, typically, is steel frame or reinforced concrete. Steel frame construction, fireproofed, is most common in seismically active areas. A steel frame can be either moment resisting or braced. For braced frames, the plan layout will have to contend with the location of the cross-bracing, which limits future flexibility. For moment-resisting construction, special welded connections are required at beam-to-column intersections. Moment frame construction is therefore more expensive.
Concrete construction is also common throughout most of the United States. Concrete construction may also consist of moment-resisting frames or, more commonly, may include shear walls, which, like cross-bracing, will limit flexibility. Floor construction may be flat slab or may include concrete joists.
Because of the need to withstand seismic forces and remain operational after a major earthquake, some inpatient facilities are now being designed with base isolation. This relatively new technology places isolation media between the columns of the building and its foundation, diminishing the effect of ground movement. Base-isolated buildings suffer less internal shaking in a major earthquake, lessening damage to buildings systems.
Designed on 380 base isolators with horizontal viscous dampers, as well as other technology to allow for a movement range of 8 feet (2.4 meters), the Arrowhead Center is a model that will be studied for future projects.
Earthquakes: A Force for Change
Although California is far ahead with seismic design, other parts of the United States along the Pacific plate and in the Midwest may find this a driving force in redesign. This is an opportunity for many hospitals to change the structure of future facilities into a contemporary model where ambulatory care is a dominant component and inpatient care is reduced but far more intense in services and care.
Because change is a constant force in design, today's designs must acknowledge that what is built for today is not permanent and will at some point become a candidate for reuse, retrofit, or removal. Therefore, the need for a comprehensive master plan that provides an "arrow" into the future is necessary. Hospital planning at its highest level recognizes this open-ended indeterminacy and creates a conceptual structure for this change.
It is to be expected that inpatient care will change and in many cases disappear. There is a need to create nursing units today that are adaptable to major change through the use of flexible long-span structures, with vertical service systems pulled out of the core to leave the floor plate as free as possible for change.
Trends indicate that virtually all patients in the future who are housed in acute care hospitals will require a level of care close to intensive care, with sophisticated monitoring. The rooms must be designed today as "universal rooms" to allow for this evolution.
Although construction of replacement nursing units is often questioned because of initial costs and the difficulty of financing, the solution to that dilemma is in the design of an efficiently staffed unit. The cost of construction is but a small part of the cost of the daily operation of a hospital. Over the lifetime of a building, construction costs have averaged only six percent of operating expenditures.
It can be demonstrated (in today's dollars) that the savings of one nursing staff member or equivalently salaried employee can save one million dollars in construction costs. The reductions in staff possible with new construction of efficient units can often pay for the unit.
Thus, the challenge to architects and hospitals is to create nursing units that are most efficient for today's operation, are flexible enough to adapt to the unknown needs of tomorrow, and provide a humanizing architecture that can be a positive contributor to the healing process.
Richard L. Kobus, AIA, is principal of Tsoi/Kobus and Associates, a Cambridge, Massachusetts-based firm specializing in healthcare, higher education, and research and development. Michael Bobrow and Julia Thomas are principals of Bobrow/Thomas & Associates, a Los Angeles firm with an emphasis in healthcare and higher education.
This article is excerpted from Building Type Basics for Healthcare Facilities, copyright © 2000, available from John Wiley & Sons and from Amazon.com.