New Orleans Hospitals Adapt And Overcome
As New Orleans marks the 10-year anniversary of Hurricane Katrina, two new healthcare facilities are replacing those destroyed in the disaster. With price tags of about $1 billion each, University Medical Center (UMC) New Orleans and Southeast Louisiana Veterans Health Care System’s new VA medical center are designed with an impressive level of redundancy and armor to protect against a future blow.
Constructed with materials to withstand 130 mph winds, built on elevated sites with sacrificial first floors, and able to be fully powered by on-site energy substations, the hospitals can maintain operations independently and uninterrupted for at least a week. Improving upon the failures of the past, they also serve as a model in resiliency for new hospitals around the country.
Surrounded on three sides by the Mississippi River, Lake Pontchartrain, and marshlands, New Orleans sits at an average elevation of 6 feet below sea level. When the levees surrounding the city broke on Aug. 29, 2005, a current of floodwaters rushed through the streets and flooded 80 percent of the city within two days. Of those who didn’t perish in the initial blow from the storm, many found themselves trapped in attics and on rooftops for days without food or water. More than 1,000 people died in New Orleans alone.
In the weeks following the disaster, at least 215 bodies were pulled from nursing homes and hospitals in the city. In the Uptown section of New Orleans, Memorial Medical Center was surrounded by floodwaters. There was no sanitation or electricity, a lack of food, and temperatures exceeding 110 degrees. It took a week for 2,000 patients, staff, and family members to be evacuated via boat and helicopter, and at least 45 people died in the facility.
At the 2,680-bed Charity Hospital downtown, generators didn’t last when the floodwaters struck. Patients in the first-floor ED had to be manually strapped to backboards and carried up dark stairwells. Staff and patients survived for a week by rationing food, scavenging what supplies they could, and siphoning gas to power portable generators. At night, they took refuge in a hot, dark facility that smelled of sewage and death.
On personal and institutional levels, Katrina was a life-changing event for New Orleans. From school policies and company protocols to building codes and structural design, the entire city has been rebuilt with a heightened level of hurricane resiliency. Hospital administrators spent years determining how to rebuild the shuttered buildings, knowing that new facilities would have to be constructed to withstand another disaster. The result is the 446-bed UMC New Orleans, which replaces Charity Hospital, and the 200-bed VA “Project Legacy,” which replaces the former medical center.
Mackenzie Skene, partner with NBBJ (Seattle), the design firm for UMC, toured some of the city’s damaged healthcare facilities two years after the storm. Seeing the damage firsthand was an important part of the design process because it allowed the team to fully appreciate possible threats. “It reinforced every day how high the water can get and what could happen. It made it clear that if they were going to put all this money and effort into new facilities, they had to be designed to survive,” Skene says.
Mark Ripple, an architect and principal at Eskew+Dumez+Ripple, a co-design firm for the VA project (the Studio NOVA joint venture team also includes NBBJ and Rozas Ward Architects), says all post-Katrina construction in New Orleans starts with a conversation about elevation. Architects typically look at a series of “lines,” ranging from the new BFE (base flood elevation) to the “Katrina line,” which is where floodwaters touched in 2005. It’s not a matter of escaping all flooding but deciding what level of flooding is acceptable and what services can be lost.
For example, both UMC and the VA project are designed with sacrificial first floors that don’t house anything critical to patient care, such as administrative office space, waiting areas, storage, equipment, and minimal clinical space, to avoid disruption in the case of flooding.
In contrast to typical hospital design, both facilities are built in an “upside-down” fashion. Air handlers are on the rooftops and generators are connected to underground fuel tanks that allow them to be refilled remotely. UMC New Orleans and the VA medical center also feature raised emergency room decks at an elevation of at least 20 feet, well above the Katrina line.
Liz Failla, project engineer for the U.S. Department of Veterans Affairs, says during high floods, the ED ramps at the VA facility can also serve as boat launches for patient transport during evacuations. “We saw during Katrina that you could only get around by boat. Interstate ramps had really worked well as boat launches. It allowed boats to easily pull up and load evacuees,” Failla says.
Also at the VA, each elevator bank features one car that doesn’t go below the second floor. Should the facility require gutting or mold remediation after a disaster, this would leave at least one working car in each elevator bank if the first floor floods. The top floor of one of the parking garages was also designed with enough reinforcement to accommodate a landing pad for a Chinook helicopter, the type that was used for evacuations during Katrina.
Fernando Rivera, director of the Southeast Louisiana Veterans Health Care System, says that as a federal project with more stringent design requirements, the VA hospital was also constructed with 30 percent more steel in the frame. The campus features a 1,200-foot-long concourse at the fourth-floor level that carries utilities, wires, and medical gas lines along with a pedestrian walkway to each of the buildings on the campus, keeping both utilities and staff out of harm’s way in the event of a flood. “You can get from building to building without going outside, even during a high flood,” Rivera says.
New Orleans has made tremendous improvements to its flood protection systems over the past 10 years. For example, the U.S. Army Corps of Engineers has spent more than $12 billion since the storm to complete levee and flood control projects in southeastern Louisiana.
While the risk of another Katrina-grade flood disaster may be small, the risk of power outages remains high. In 2012, the mild Category 1 Hurricane Isaac knocked out power to more than 1 million homes and businesses across southern Louisiana, leaving some in the dark for weeks. “Power loss is a threat every single summer. We needed not just emergency power but 100 percent full backup power to keep everything running. [The system] is designed so that if you’re in the building, you won’t even know it lost power,” Failla says.
Scott Landry, senior vice president of facilities for LCMC Health, the organization that operates both the new UMC New Orleans and VA hospitals, learned during Katrina that facilities need to be able to survive longer without help from the outside world. To that end, the hospitals each feature their own on-site energy substations that can support the facilities with full operating power for at least a week.
Architects engaged in extensive discussions and
analysis about how long facilities had to sustain themselves. They worked through scenarios and past history to determine necessary requirements to support everything from HVAC systems and chilled water to critical equipment and even televisions in the lobby. Landry says the power plan started with changes in policies to minimize the human loads on buildings during a hurricane. In the past, it was common for hospitals to allow employees to bring their families to shelter in place.
During Katrina, many hospitals, including the old Charity Hospital and the VA site, sheltered thousands of staff family members. This not only increased the need for services but made evacuations more complex and difficult. Landry says hospitals now help staff find shelter for families elsewhere to reserve space for patients and caregivers: “It starts with having fewer people here. We try to reduce census so we can focus on [patient care] and housing required staff, and to reduce energy consumption.”
The UMC and VA projects also accounted for full HVAC operations during power outages, something Failla says isn't just about comfort. As hurricanes strike in late summer, days without power can send unventilated parts of buildings into triple-digit temperatures. “Heat starts going up, machines start shutting down, and you can have serious problems. It can get so hot, it’s also a health issue,” she says.
From plan to action
Even the most secure facilities aren’t effective without a solid emergency plan. Rivera says the VA has multiple levels of procedures to guide storm preparation and response. Most are based off of hurricane designations set by the National Weather Service National Hurricane Center, and threat levels help dictate operations, staffing levels, and closures at the facility. “The bricks and mortar are a part of it, but you need to be able to activate [the facility] and have policies to transfer from a normal environment to an emergency,” he says.
Approaching storms call for tough decisions. While the majority of storm systems weaken or turn at the last minute, no one can accurately predict the severity or path. Locking down a hospital too early could be a disservice to patients, and doing it too late could put people in danger. Both the VA and UMC New Orleans projects were designed to respond to threats at multiple stages. At the earliest, it starts with putting procedures in place to secure the campus, ensuring there are no flying materials on-site and preparing to move staff and patients where they need to be in the hospital. Elective surgeries are cancelled and patients who can be discharged early are sent home to minimize the load.
UMC New Orleans opened in August and the VA medical center is scheduled for 2016. Ripple says the designs of the new hospitals and other buildings in the city represent a change in attitude about how New Orleanians view the risk of flooding.
He says the city is slowly embracing buildings that are flexible and adaptable, pointing to raised structures, redundant power supplies, and “floodable” spaces around the city as a smarter way of learning to live with the risk. “We just can’t keep building higher walls thinking we’re going to keep the water out. We’re surrounded by water and we’re adapting our city to live with it,” he says.
Craig Guillot is a freelance writer based in New Orleans. He can be reached at firstname.lastname@example.org.
SIDEBAR: Inspired Design
Fernando Rivera, director of the Southeast Louisiana Veterans Health Care System, says the VA medical center replacement, Project Legacy, was designed at a time when the system was changing its patient care model to be in line with a nationwide trend to reduce noncritical hospital stays by bringing more patient care to homes and clinics.
Reducing that load allowed the New Orleans project to focus more on creating a comfortable space designed for short-term stays. Because many patients and families have to travel from up to five hours away, the facility has larger rooms to accommodate family members. Amenities and family-friendly features include large oak trees around the campus, 11 gardens, temporary housing facilities, abundant seating, and beverage and snack stations near all entrances.
One unique element at the VA hospital is the rehabilitation center. When contractors demolished multiple city blocks to clear the city, they salvaged four historic homes, relocated them to the grounds, and converted them into transitional living residences. One is set up like a typical home to help veterans learn to manage day-to-day tasks. Another was set up with physical rehabilitation equipment, and two others will be used for outpatient mental health.
Liz Failla, project engineer for the U.S. Department of Veterans Affairs, says the homes also serve as a buffer between the new medical complex and neighborhood. “They have historic value, but being able to use them for patients really brings a more comfortable, homelike environment,” she says.
Rivera says the new hospital was designed with significant input from its specific population of patients. Everything from the placement of bathrooms and snack areas to signage and layout of the rooms was designed to appeal to veterans. Because some have issues with hypersensitivity, designers also reduced blind angles, increased the seat spacing, and made signage more prominent and visible.
The hospital was also designed with input from staff to improve their work efficiency and safety. Failla says every inpatient med/surg room features ceiling lifts that go from the bed to the bathroom. All rooms are also same-handed to improve response time; nurses’ stations have been strategically placed with buffers between patient rooms to minimize noise.
SIDEBAR: Rising In The East
New Orleans East has been one of the slowest parts of the city to recover from Hurricane Katrina. Years after the Pendleton Memorial Methodist Hospital was destroyed in the storm, there was little will to rebuild a hospital in one of the lowest parts of the city that was likely to flood again. While planning for the hospital began right after the storm, it was held up by red tape and politics before things moved forward after a change in leadership at the mayor’s office.
The replacement project eventually got off the ground in 2010, and the $130 million, 80-bed New Orleans East Hospital opened in June 2014, hailed as a big step in the area’s recovery.
Unlike the city’s other new hospitals, University Medical Center New Orleans and Southeast Louisiana Veterans Health Care System’s VA medical center replacement, which had billion-dollar budgets, the 216,000-square-foot, three-story facility was a city-funded project. Backed by a loan insured under the FHA Section 242 Hospital Mortgage Insurance program, the smaller capital investment required designers to carefully optimize the facility for hurricane resiliency.
Mark Ripple, architect and principal at lead design firm on the project Eskew+Dumez+Ripple (New Orleans) says the team went through a number of scenarios to determine what level of protection would be appropriate and fit within the budget. “We spent a lot of time thinking about [Level 5 protection], and the cost to benefit was simply not achievable within their budget. Having that conversation early on helped inform all other aspects of the design,” says Ripple.
In the end, it was determined that New Orleans East would be built to Level 2 protection, meaning the entire facility must be evacuated within 72 hours of a storm.
Despite budget constraints, there were elements of the project that were in
spired by the VA medical center’s design. For example, the hospital features a metal and glass exterior that can withstand 130 mph winds and all mission critical functions are on the second floor, with a ramp leading up to the ED dock able to serve as a boat launch during high floods.
The central plant and utilities are located on the roof, and three rooftop generators are connected to an 18,000-gallon fuel tank serviced by a pump raised 18 feet above ground. The features are enough to keep the hospital functioning for about 96 hours, even under extreme flooding and wind from a Category 3 storm.