Frank Gehry is probably the most prominent living architect to fit the moniker of the “starchitect.” His design of the Guggenheim Museum transformed the nondescript Basque industrial town of Bilbao into a tourist attraction, and his Disney Concert Hall became built evidence that culture in Los Angeles is not exclusively the domain of Hollywood. The fact that Gehry is now designing the Cleveland Clinic Ruvo Center for Brain Health in Las Vegas signals that healthcare facilities are becoming architectural icons, on par with opera houses, concert halls, and art galleries.

But “starchitecture” has never been able to succeed without the support of “starengineering”-as anyone who has seen the enormous trusses holding up the flamboyant curves of the Disney Hall well knows. The role of the engineer as enabler of iconic design becomes even more significant in the highly regulated, budget-conscious realm of healthcare design.

Hospitals have been lacking a high-level aesthetic dimension for several reasons: their need for functionality, the enormous number of different uses that have to be accommodated, and the large number of regulatory and fiscal requirements that have to be met. But luckily, a number of technological innovations are allowing engineers to help architects realize their creative vision and enable them to put their best design talent to use, even in an environment as complex as healthcare.

Towards iconic patient-centered design

For the most part, challenging life experiences occur in healthcare facilities, including cancer centers, rehabilitation facilities, and emergency rooms. And traditionally, the design focus has been function over form. Yet while design cannot eliminate disease, it can alter the experience of the patient (and the visitor) by responding to the human need for comfort and serenity. Studies in evidence-based or patient-based design have shown that certain environments can even help patients recover more quickly.

Ideally, a hospital will have rooms with dedicated space for patient, family, and staff activities, sufficient infrastructure capacity for in-room procedures, and maximum daylight exposure. Bathrooms will have double-door access to help caregivers and staff assist patients on foot, in wheelchairs, or in bed. High-efficiency filters or 100% outside air will be used to improve indoor air quality and reduce recirculated air. The new model hospital will be a peaceful environment with artwork displays, piano music in the lobby and other common areas, and green spaces with fountains and benches.

While healthcare design may not yet be able to compete in creativity with structures dedicated to culture and the arts, it has come a long way from the weighty brick and concrete boxes of yesterday. Architects and designers have been creating more transparent and colorful façades. Welcoming campus-like layouts now include elements like coffered ceilings and atriums that are designed to increase patient comfort. The significance of the engineer's role in healthcare facility design has increased along with such features as asymmetrical floor plans, complex structures with different ceiling heights, as well as stricter codes regulating daylight access and infection control.

Only thoughtful and innovative engineering in collaborative partnership with client, architect, and interior designer early on in the design phase can ensure that an architectural vision can in fact become reality. By using computer tools like intelligent building systems, and building information modeling (BIM), the engineer can provide both architect and medical staff with a conceptual idea of the look and feel of the planned facility. A database for mechanical equipment that stores proprietary data makes it easy to ascertain how a choice of building material and/or mechanical systems early in the design process will affect energy usage and comfort, and what adjustments can or need to be made to meet client requirements.

Syska Hennessy applied this approach successfully on a recent mental health project in New York state. By clustering the points with the highest levels of mechanical equipment noise and vibration, using advanced computer design tools, the architectural and clinical planners and engineers were able to isolate them and assign appropriate program functionalities. Creative engineering made sure that building systems remained unobtrusive and became an integral part of the design. The result: an aesthetically more pleasing architecturally-focused design, and a more patient-friendly facility.

Safe and save

Due to the importance of airborne infection control, hospitals typically have more air exchanges than offices or schools. Highly sophisticated HVAC systems are a critical part of the design and efficiencies in heating and cooling systems are necessary to keep operating costs at bay and to possibly seek LEED certification.

The new iconic healthcare designs make it much more challenging to calculate and predict air movement by traditional means. By using computational fluid dynamics modeling (CFD), engineers can take into account all the relevant factors-air velocity, temperature, internal and external loads, and especially important for healthcare design, particle count and dispersion. This allows the design team to gain a better understanding of what temperature and air velocity should be designed for each clinical area throughout the facility and enables them to design a better infrastructure that promotes patient health.

To accommodate daylight requirements and create public space, HOK designed an 850,000-square-foot medical center at a midwestern university as a two-wing facility around an atrium. This allowed for double-loaded corridors. From an engineering perspective, the clever design solved one problem, but created another, namely heat build-up in the atrium negatively affecting patient comfort on the upper floors. Using CFD enabled the engineers to model air temperature and air movement conditions throughout the space and work closely with the architect and interior designers to identify the best placement for specific diffusers that would provide maximum comfort and minimal noise while maximizing aesthetics.

At a second midwestern hospital HOK and Syska Hennessy provided a detailed CFD study of a 3-story atrium connecting a new 841,000-square-foot acute care hospital to a 175,000-square-foot ambulatory care facility. Two unique aspects of the project are the different hours of operation and the different clinical standards for filtration and pressure relationships. The hospital is 24/7 while the ambulatory care facility is open for 12 hours, five days a week. This necessitated a model to integrate pressure relationships for occupancy as well as security requirements. On this project the high-performance energy modeling team is exceeding ASHRAE 90.1 standards and incorporating 100% outside air into patient areas programmed for highly infectious patients. A silver LEED certification or higher is the ultimate environmental project goal.

The most critical cost-saving strategy supported by technology is undoubtedly Smaller Volume Buildings. By replacing one large centrally placed air shaft with geometrically designed multiple shafts with smaller footprints, hospitals can realize substantial savings that result from decreased building height and volume (e.g. less building material, lower energy and construction costs). Therefore, a much smaller percentage of floor area needs to be given over to building systems. At a private New York City medical center a total of 24″ was shaved off a 125,000-square-foot building, saving close to $1 million in costs, according to the builder, Turner Construction.

Yet while design cannot eliminate disease, it can alter the experience of the patient (and the visitor) by responding to the human need for comfort and serenity.

An unusual façade, nonrectilinear footprint, and complex floor plan-all these elements of iconic designs
are challenging from an engineering perspective. Given that healthcare architecture is increasingly moving in that direction, it is important for engineers to realize that they are no longer just engineering the mechanical systems, they are engineering the architecture as well. A close collaborative creative partnership between architect and engineer-and of course, the client-will create the best possible patient experience and ensure a speedier way towards recovery. HCD

Best in Class:

University Medical Center at Princeton Replacement Hospital and Central Utility Plant, Plainsboro, NJ

University Medical Center at Princeton, the acute care hospital of the Princeton HealthCare System, has been a teaching hospital for the past 30 years, and has served the healthcare needs of Central Jersey residents since 1919. Currently under construction is a replacement hospital, to be known as University Medical Center of Princeton at Plainsboro, an architectural joint venture of HOK/RMJM Hillier.

When it opens at the end of 2011, the replacement facility will be 600,000 square feet, with 237 single patient rooms on 50 acres of a 160-acre site along the Millstone River in Plainsboro, New Jersey. It will have expansion capabilities for an additional 324,000 square feet and 160 single patient rooms. Designed to accommodate 21st- century emerging technologies and treatments in healthcare, as well as sustainability, the hospital will be the hub of the 160-acre health campus, which will become a destination for life-long health and wellness care services, including a rehabilitation and nursing facility, pediatric services, fitness center, education center, and medical office building.

The single patient rooms, as well as the public spaces, will be designed with features that reduce stress and anxiety. Research has shown that properly designed spaces with maximum natural light will minimize hospital-acquired infections, improve patient safety, enhance privacy, improve communications and confidentiality, and speed recovery.

From a functional perspective, the design tries to achieve the highest possible degree of infection control through the use of a purist air system, while creating an energy-efficient 600,000-square-foot, 237-bed hospital. To achieve this, the engineering team focused on energy simulation and the modeling of daylighting. This involved several studies for the exterior climate wall on the building's south façade. The team calculated the solar effects of each option for high-performance glass, angled shading, fritted glass applications, and climate wall. In response to the study results, the client decided to invest in a new chiller plant, a high-performance façade, and 100% outside air mechanical systems.

Designing Outside of the Box:

St. Vincent's Hospital Manhattan Replacement Center

St. Vincent's Hospital is one of the longest-serving medical facilities in New York City. The hospital is part of the Greenwich Village historical district. Linear, rather boxy with a brick façade, the facility tries to make the most of its crowded urban site. The 641,000-square-foot, 19-story replacement building diagonally across the street site-slated for completion in 2015-is quite a different story. Designed by Pei Cobb Freed/Ballinger, it calls for a lenticular tower on a rectilinear podium and features a glass and terra-cotta exterior. The new 366-bed facility will support inpatient activities and provide an environment for hospital staff to deliver more efficient diagnostic, treatment, interventional, and emergency services.

Taking all the building systems from a large square and making them fit into a lenticular envelope is not an easy feat. It's the proverbial fitting of the square peg into the round hole. Large mechanical systems have to be collected from a rectilinear room and routed up to a very narrow, convexed-shaped distribution. In addition, the landmark status of the neighborhood means tight measurement specifications to allow construction in an historic district and high emphasis on an energy-efficient façade.

At the earliest stage of the concept design phase, Syska Hennessy's engineering team used an energy model and BIM/3D design to help select the proper amount and type of glass for the façade as well as roofing materials that would support the architect's vision of an aesthetically pleasing building skin, while ensuring approval from the New York City Landmark Preservation Commission and meeting the client's ambitious guidelines for energy efficiency. The resulting project was strongly endorsed recently by the New York City Landmarks Preservation Commission and is now undergoing reviews by the New York City Planning Commission and New York State Department of Health.

William Caretsky is Senior Vice-President at Syska Hennessy Group.

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Healthcare Design 2010 May;10(5):48-54