Rethinking the Critical Access Hospital
Completion Date: April 2010
Hospital Administration: James E. Tyler, Vice-President/Hospital CEO
Architecture and Interior Design: Architectural Alternatives, Inc., Carilion Design Group
MEP Engineering: Harrell, Saltrick & Hopper
Structural Engineering: Day and Kinder Consulting Engineers, PLLC
Civil Engineering: Thompson & Litton
Construction Management: Skanska USA Building, Inc.
Total Building Area (sq. ft.): 86,000
Construction Cost/sq. ft.: $279
Total Project Cost: $34,000,000
Carilion Giles Community Hospital in Pearisburg, Virginia, is a critical access hospital conceived with a need to replace an aging 1950s-era facility. Early programming indicated the Hospital needed to expand significantly with many departments needing to increase by two to three times their present size. Initial facility assessments were pointing to the need for significant physical and equipment upgrades; electrical and mechanical systems were at capacity. A comparative design study-whether to renovate the existing facility or construct a new facility-was performed. That study showed that by far the most cost-effective direction was to begin the planning for a totally new facility with a majority of new equipment on a new site not far from the existing hospital.
Unique to the project was the onboard collaboration with a trusted Construction Management firm (Skanska USA Building, Inc.) which made it possible to explore various planning and design scenarios with associated cost information. Also unique was the hospital's relationship with the local Giles County Industrial Development Authority, which offered the new 26-acre site in trade for the present hospital building and property. The vision was for the new hospital to become the first occupant, prime generator, and focal point for an overall 150-acre development planned to include medical offices, retirement homes, and other facilities creating a comprehensive planned community. The Authority spent $2.5 million including grading and bringing utilities to the overall development.
With the initial comparative planning studies completed, the more definitive programming and design work began in late 2006. Overall planning goals were identified to guide the design of the new facility:
create a 25-bed hospital that will facilitate necessary staffing efficiency and friendliness;
create design elements that embody indigenous elements of a patient-centered design in a rural community;
plan the facility in such a way that will allow easy expansion of all the major departments without displacing or altering newly constructed departments;
create internal flexibility to maximize space utilization;
provide easy wayfinding for patients and visitors;
provide a clear separation of traffic between outpatients and visitors from inpatient transport, clinical staff traffic, and treatment/diagnostic work areas; and
provide physical separation between institutional and noninstitutional functions to minimize construction costs.
Site and plan organization
The site is located in a mountainous rural area in the western part of Virginia, approximately 30 miles west of Virginia Tech, a major state university. The hospital market area includes surrounding Giles County and adjacent Monroe County, West Virginia. The 150-acre development was composed of hilly terrain and needed extensive grading for access drive and individual building parcel development. The hospital site has a relatively high elevation with spectacular views of the surrounding mountains and valley areas. Building placement is organized along a former ridge line with an east/west orientation which suggested, because of prevailing northwest winds, that the Helipad and Emergency Department be located on the north side of the building. The hospital site is served by a point of public vehicular entry on the east side which drove the main public entry being located on that side (figure 1). From this point of origin, the building organization began.
The hospital is designed as a single-story, 86,000-square-foot facility (figure 2). All major treatment and diagnostic functions are organized along the northern side of the building along with the Ambulance Entry and Mobile MRI docking area. The southern side houses Outpatient, Administrative, Lab, Material Management, Dietary, Engineering/Mechanical, and Receiving areas. A central core houses Outpatient Routine Diagnostic and Respiratory Therapy areas, Pharmacy, HIM/QA/UR, and Social Service areas, On-Call, and other Support functions. A Staff/Inpatient Corridor serves the central core and all Treatment/Diagnostic functions along the northern axis and connects with the Inpatient Nursing Unit, which offers inpatient privacy during transport. A Public/Visitor/ Outpatient Corridor along the southern axis connects the Public Entry, Lobby and Waiting areas with the Inpatient Nursing Unit and Café for complete separation from clinical traffic. The core also serves to separate institutional from noninstitutional occupancies, which are less costly to construct.
All major departments-Surgery, Emergency, Imaging, Rehab Therapies, and Clinical Lab-are located around the exterior periphery of the building and are planned to allow future expansion without displacing one another or requiring internal departmental reorganization. The southern Inpatient Nursing Wing is also planned for future expansion if needed.
Plan efficiencies were incorporated into the design to enable staffing efficiencies and to promote patient and user friendliness. One point of entry is utilized for all patient types, including walk-in emergency. The Patient Access Department is located immediately adjacent to the Main Entry, which will be staffed on a 24-hour basis and is the single point of access to all patient services. Also immediately adjacent to the Main Entry is a volunteer-supported reception, information, and hospitality station to support initial contact user friendliness. All outpatient waiting is located at the Entry Lobby area surrounded by all outpatient departments, promoting easy wayfinding (figure 3).
The Entry Lobby and Waiting is a tall-ceilinged area with a ribbon of connected high-wall areas providing surfaces for a commissioned mural, approximately 80 feet long, by a well-known local artist, Robert Tuckwiller (figure 4). Titled “Seasons of Life,” the mural depicts familiar landscapes and landmarks of Giles County evolving through the seasons of the year and human experience, offering a sense of place and familiarity.
Immediately off the Main Waiting is a function new to the Hospital called the Routine Diagnostic Center. Respiratory Therapy is housed in this area and will be the location where routine outpatient lab blood draws and EKGs are made. The primary function will be to provide examination and consulting space for visiting specialty physicians.
Along the path to the Inpatient Nursing Unit is the Café (figure 5), designed to serve all hospital users. The Café has a view to the exterior dining courtyard, adjacent Memorial Garden offering quiet contemplation, and views to the mountains beyond (figure 6).
Upon entering the Nursing Unit, a small family sitting area is located along a glass wall overlooking the Courtyard and Memorial Garden, inviting images of familiarity and well being. Within the Nursing Unit, the design intent was to create a patient-centered, low-stress healing environment. Large windows offer all patient rooms-including all ICU/Special Care Unit Rooms-views from the bed to the surrounding mountains and valleys (figure 7). When walking down a patient wing corridor, one sees at the end of each a small sitting area surrounded by glass with refreshing views-a friendly, familiar, healing destination. All patient room doors are inset off the corridor to create a sense of buffer and offer a residential feel (figure 8).
A program requirement to promote nursing staff efficiency was to connect the ICU/Special Care and general Nursing Unit stations (figure 9) so that nursing staff could flex between the two according to patient census. This was accomplished by centering the ICU/Special Care Unit within the Nursing Unit and providing an open connection, with a staff/physician work area, to the central nurses' station. A large skylight directly over the nurses' station adds warmth and congenial feeling to the central nurses' station, surrounding corridors, and interior work areas.
A similar concept combining nurses' stations for staffing efficiency is incorporated in the OR Suite to enable nursing staff to flex between the OR and Recovery areas.
Internal flexibility was a major consideration in planning for the Emergency Department (figure 10). Outpatient Surgery is located directly adjacent and opening into Emergency, offering nine additional treatment bays and support areas in time of need. Similarly, Cardiac Rehab and Physical Therapy functions are able to flex between each area and benefit in terms of Staff coverage. Respiratory Therapy is planned to flex into the Routine Diagnostic area for its outpatient needs.
Supporting user friendliness, all interior finishes were selected to mimic prevalent and familiar natural exterior colors. Furnishings were designed and selected to be compatible with local culture which is steeped in history, evoking a tradition of artistry and craftsmanship. These attributes can be seen in the cabinetry design and regional art selected for the public spaces. The selection of wood and stone-like products promotes the rural atmosphere desired.
At the time of writing, the Hospital was in the process of phasing its occupancy of the new facility, which in itself presents an interesting challenge. However, as expressed by Vice-President and Hospital CEO James E. Tyler, upon hearing the many positive Staff and visitor comments during the recent dedication and public open house functions, the forethought given to meeting the challenges of providing an efficient, staff- and patient-friendly environment, will be key to the overall future success of the Hospital. HD
Michael W. Beachy, MArch, RA, is a corporate Architect with Carilion Design Group, a subsidiary of Carilion Clinic, Roanoke, Virginia.
For more information, visit www.carilionclinic.org.
Healthcare Design 2010 June;10(6):30-38