HEALTH CARE: Bridges of Hope

When Marian Walsh stood before the cameras in Toronto on a sunny day in June to announce the expansion of the Riverdale Hospital, she pointed to ironical circumstances that are putting pressure on the health care system.

“We must remember,” she said, “that the major accomplishment of medical science in the last 50 years has been… not the eradication of disease…. The major accomplishment of modern medical science has been the discovery of treatments that allow us to live with disease and disability.”

As the president and chief executive officer of a hospital that specializes in what is currently called “complex care,” Walsh lives every day with people who have had strokes and heart attacks, and patients suffering from incurable diseases like AIDS, Parkinson’s and Multiple Sclerosis. These are individuals whose bodies are so badly damaged they can never return to normal life. Nevertheless, they deserve to have an existence as long and fulfilling as possible.

Within the crowded, dingy walls of the present 1960s Riverdale hospital at the foot of the Don River in Toronto’s east end, Walsh’s staff also gives palliative care to those who have less hope — those dying of cancer, or suffering in the last stages of kidney disease. And for others, as Walsh says in an interview later, the hospital is “a resource, not a destination.” In the rehabilitation unit, people — often the young who have been severely injured and traumatized in accidents — re-learn how to move their tortured bodies and how to wield equipment that helps them lead relatively independent lives.

Riverdale is to become the Bridgepoint Health centre as it expands its services and takes over the historic 1850s Don Jail next door. The austere but beautiful architecture of the Victorian era prison will house the hospital’s administration offices. (Local historians are delighted the building is being saved.) On a “campus” that covers over eight acres, the $144 million expansion will see the construction of a long-term complex care facility with 160 beds. There will be a community rehabilitation centre and a research institute. The existing hospital will be upgraded and given 96 new beds. The entire complex will continue to focus on people with severe needs, but with the idea of widening its scope to offer more of a continuum of care and readjustment for patients after they pass the critical stages. Hence, the “bridge” imagery in the new name. “The concept of Bridgepoint,” Walsh explains, “is that we will bridge people from one level of care to another — from hospital to long-term care to the community; from sickness and dependence, to a more independent level of care and lifestyle.” She suggests society has a duty to offer patients this service: “In the face of a growing population of people who now live with complex disease and disability — that’s the success of modern medicine — we need to provide a range of options so that these people can live in a variety of places outside of hospitals.”

We’ve found technologies to make people live longer, in other words, but these are not miracle cures. Many of the treated people will need care for the rest of their lives.

Boom days

The expansion of Riverdale is just one of a multitude of transformations taking place in hospitals across Canada. Despite the turmoil wreaking havoc in the public health care system over policies and funding, the construction of new hospitals and additions proceeds apace. Cranes swing above “H” signs, scaffolding rises, while chaos and confusion reigns in the wards below. By early summer Roy Romanov is bogged down in public hearings to decide whether or not the federal government should support increased privatization. The provincial governments are straining at the leash of federal policy and protesting loudly that they don’t have enough money to support current levels of service. Emergency rooms turn ambulances away and health drug costs soar. Hospital administrators, desperate to avoid deficits, juggle budgets and order more “efficiencies.” Staff in the trenches feel exploited and overworked. Nurses, having been told a few years ago to look elsewhere for work, are now in short supply. The latest region of discontent is Manitoba, where 89% of the 10,000 health care workers voted to strike in early July.

All this hullabaloo in the corridors of power over healthcare is not stopping governments from digging in to build new facilities. In its 2002-2003 Budget Quebec promises to earmark “a major portion” of $500 million “for the construction and renovation of residential and long term care centres, and for the expansion and renovation of hospitals, particularly emergency rooms.” In Montreal a huge reorganization is planned, with closures and amalgamations of several hospitals to culminate in the building of two mega-hospitals, one at McGill University, and one at the Universit de Montral. It’s said that the McGill University Health Centre “superhospital” will be over three million square feet. British Columbia’s new regime is cutting back in all quarters, but health care buildings are still the second largest item on the province’s capital expenditures budget for 2002/2003. They’ve been allocated $273 million. The only sector receiving more funds (almost twice as much) is education. Alberta currently has $1.46 billion approved for health care projects. The Ontario government seems to be the biggest spender. Its SuperBuild program published a list of just “some” of the hospital projects under way that named 25 new hospitals or additions worth a total of $1.7 billion. The list doesn’t include more recent projects such as the $144 million Bridgepoint centre.

What this spending translates into for consulting engineers who have forged a niche in health care buildings is lots of work. A firm like Rybka Smith and Ginsler, consulting engineers of Toronto, has been specializing in hospital work since 1949, and now has offices in Toronto, the U.K. and the U.S. Richard Armstrong, P.Eng. says approximately 50% of the work being done in the Toronto office is in the health sector. He says they are involved in “numerous” hospital projects at various stages of design and construction.

Another Toronto firm that is benefiting from the boom is H.H. Angus. Principal Nick Stark, P.Eng. can trot out name after name of projects they are working on. Among them are a 682,000-s.f. new regional hospital in Thunder Bay, a 220,000-s.f. new hospital in Cobourg, and another about the same size in Parry Sound. They are also doing major additions to Toronto hospitals such as a new $128 million clinical services building for the University Health Network, an amalgam of Toronto General and other hospitals. They are adding 235,000 square feet to North York General’s existing 400,000 square feet. Then there is South Lake hospital in Newmarket, St. Joseph’s hospital in Hamilton … “I could keep going,” Stark says.

He is grateful for the healthcare work, but he’s aware there are dangers if it makes up too big a proportion of their business. “To be honest you don’t want it to be too much. It’s subject to the whims of politicians. There was a time 20 years ago when they just stopped everything and put it on hold. But there has certainly been a boom in it recently.”

Stark says the hectic pace started in Ontario about five years ago when the government instigated the Health Services Restructuring Commission. They were to go around the province and recommend closing some hospitals, amalgamating some, and expanding others.

Stark thinks the government took on more than it had bargained for: “I would say they [the government] seriously underestimated the impact of what they set out to do.” They apparently didn’t appreciate the complexities of hospital building. While it may seem simple to propose a small addition to a facility, say for new operating rooms, Stark says, “What if the existing OR’s are in the middle of the building? You can’t put two somewhere away from the others. So then you need a new surgical department, and a whole chain reaction happens.” As a result of such complications, several of
the plans for renovations or additions were abandoned, and instead consultants were asked to design “greenfield” hospitals from scratch.

The technology squeeze and the campus

Faced with renovating the Riverdale hospital, Marian Walsh knows it’s going to be a challenge to bring the old building up to par. There has been a hospital on the site since 1872 when Toronto began sending smallpox victims out to the House of Refuge, which was then on the outskirts of the city. However, the main hospital building being renovated dates from the 1960s.

Aside from the simple lack of space and amenities in the existing building — some rooms have four patients and no washroom — the hospital today has to accommodate patients who have a host of different technological needs. “The type of patient we’re getting, the level of complexity that we’re dealing with, is certainly a lot greater than it was 10 or 15 years ago,” says Walsh. “In complex care and rehabilitation hospitals, we’re providing the kinds of services that usually were found in acute care.”

Hospitals have to squeeze more and more high-tech equipment and services within their walls. Walsh describes the mounting array of technologies they provide. “For example, we have a dialysis program for people with end-stage kidney disease. You wouldn’t have found that 10 years ago. We’re operating palliative care programs for the last 10 to 20 days of life, so we’re providing complex drug therapies and other things for pain and symptom management. We’re dealing with people with end-stage respiratory disease. We need things like piped-in oxygen. We’re using things like infusion pumps, intravenous therapies and so on.”

The hospital needs to provide plug-in electrical outlets beside each bed so that patients can recharge their wheelchair batteries. In a facility where, “we can hardly fit visiting chairs next to beds,” most patients manoeuvre around in wheelchairs. “Seventy per cent of the people that we serve have severe functional limitations, so 70 per cent of them are in some kind of motorized device that we have specially built for them to enable them to be independent.”

And as drug therapy becomes more complex, it too affects the building design. “We are dealing with different arrays of drugs that have much more serious implications for people,” says Walsh. Laboratories must be fitted out with ventilation hoods, humidification, and automated equipment that allows staff to calibrate the chemicals precisely.

Consulting engineers and architects who design hospitals have always had to juggle with an enormous number of details, but as technology advances, the web of complexity they face is growing.

“The delivery of healthcare has rapidly changed over the past decade,” says Armstrong. He sees the changes driven both by technology and the new policies to move patients quickly out of the acute care wards: “There has been an influx of new medical technology and systems, which have impacted healthcare facilities. Furthermore, the shift from inpatient to outpatient services has had a dramatic impact on the facilities’ configuration, size and operations.”

The hospitals that survive restructuring are coagulating as huge “co-location” complexes that offer a whole range of services and treatments on their sites. They are often called campuses, but inside they are more like small cities, hectic with people and activity of all kinds.

The Bridgepoint “campus” has its cluster of five different components. Another Toronto conglomeration is the $67-million Bloorview MacMillan Children’s Centre to be built this fall to replace the existing facilities on Bayview Avenue. A 300,000-s.f. rehabilitation and continuing care complex for children, it will have three in-patient care units, a school, cafeteria, daycare, pools and a gymnasium, as well as centres for research and education. Then there is the 10-storey “vertically integrated campus” being added to St. Joseph’s Hospital in Hamilton, Ontario. It is the regional centre for kidney transplants, renal dialysis, respirology and specialized mental health services. Some floors in the new tower will have laboratories, others will house patient care with 146 beds, and the rest will be a teaching and conference centre, including an auditorium.

Despite the high volume of hospital work, designers are not able to find economies by adopting a cookie-cutter approach. Nick Carter, P.Eng. electrical engineer at H.H. Angus, says hospitals are probably the most complex building type. “There are so many different systems. Every room — or just about — is custom designed.”

Infection control

Often when engineers are asked about new challenges they face when designing hospitals, the first issue they think of is infection control. The resurgence of tuberculosis “TB,” the number of AIDS and HIV positive patients, spread of drug-resistant bacteria and risks from strange viruses like Ebola, have resulted in much more attention being paid to the spread of disease and the role of buildings.

Heating, ventilating and air-conditioning systems come under close scrutiny as possible harbours of infection. New standards are in the works as a result. The American Society of Heating Refrigerating and Air Conditioning Engineers (ASHRAE) is proposing a new standard SPC 170P, Ventilation of Health Care Facilities, and Nick Stark was chair of a committee that wrote CSA 317.2 “Special Requirements for HVAC systems in Healthcare Facilities.” It was released last year.

Isolation rooms are one area Stark’s committee considered. “It used to be that you could have an isolation room that had a switch on the outside,” explains Stark. “One day it was a so-called positive pressure room, then you could throw the switch and it became a negative pressure room.” A TB sufferer, for example, is kept in a room under negative pressure so that the air he or she is breathing stays within the room.

Today the function is not changeable, Stark explains. The rooms also have to have a complex armature of alarms, and the air is more precisely controlled.

He lists some requirements in the new standard for a negative pressure room. There must be directional airflow within the room, non-aspirating diffusers, and a low level exhaust near the head of the patient bed. All air must be exhausted to the outdoors through a dedicated system. Where the air is not discharged clear of building openings the designers must specify HEPA-filtration.

“Some of these issues would have been covered before,” says Stark, “but the new standards are definitely more stringent than they used to be. The requirements developed out of the research and literature by the Center for Disease Control in Atlanta. In 1994 or ’95 they issued a report because they were getting a big increase in TB in the States.”

Operating rooms are designed according to a clean room approach. HEPA filters are used for microbial controls, and air is supplied through laminar flow diffusers to ensure it is brought in over a large surface area at low velocity in the ceiling. For a typical surgical unit mechanical engineers would have to provide services such as medical vacuum, medical air, oxygen, nitrous oxide (for anaesthetic), high pressure nitrogen (used to drive the tools), and carbon dioxide (used for inflating cavities and chilling). In the most recent hospitals the gases are brought in on articulating service arms that look “fairly space age” says Stark.

To control water-borne infections Armstrong says hospitals are using instantaneous hot-water heaters that raise the temperature of water from the tap to 170 degrees Fahrenheit, effectively sanitizing the water similar to the pasteurization process. Hands-free sinks at the entry of each patient room are also usually required to control the spread of infection through contact.

Mould and mildew in the walls can cause infections, and have been the cause of a crisis in at least one older hospital. The Royal Victoria Hospital in Montreal had to close 12 operating theatres between March and July last year after a patient died and mould found in the walls was suspected.

And because hospitals are consta
ntly renovating their facilities, building designers and contracts will now have to be careful of infection emanating from construction sites, whether through dust and dirt or other means. The Canadian Standards Association is developing a standard, “Infection Control During Construction or Renovation of Health Care Facilities.”

One of the biggest challenges for the engineers working in retrofit projects is simply finding space in the existing ceiling to fit in the extra air ducts, power and communications equipment that are required today.

Energy & Electricals

Ventilation rates in health care facilities are high and rising. A recent AIA guide developed with ASHRAE suggests six air changes per hour in patient rooms, for example, and up to 12 in critical care areas. The fresh air is good for patients’ health but it uses a lot of energy. Stark says that even though a building today will have a tightly sealed building envelope with superior insulation and glazing, it may use more energy than an older building because of the increased demand for power to heat or cool the vamped-up air supply.

In the areas where 100% fresh air is required, engineers often use heat recovery wheels on the air handling units to offset the energy needs. On four of the 27 air handling units to be installed on the roof of the regional hospital in Thunder Bay, for example, H.H. Angus has specified an enthalpy wheel with a molecular sieve that allows the transfer of water but not contaminants.

Energy efficient lighting reduces the energy consumption. According to Carter, T8 and T5 fluorescent tubes are now the standard. In one new hospital he has also specified LED area lighting for night lighting in hospital wards. Used in exit signs for years, but now making inroads as a source of general lighting, LED systems have an extremely long life of up 100,000 hours, creating a big savings in maintenance.

Armstrong believes that computerized building automation systems have had the most profound effect on the use of energy because they allow it to be tightly tuned and controlled to respond to different demands. Today large chiller plants, for example, can closely track the demand for chilled water and react almost instantly.

Cogeneration has been “studied to death” according to Stark, but because of its high capital cost and the volatile energy market, it has not been actually implemented in many projects.

For the electrical engineer, Carter says there have been “huge changes” in providing a communications infrastructure. Since deregulation the consultants are responsible for designing the wiring for telephones and data outlets that are “everywhere.” They tend to use high-volume, high-speed fibre optic cables for the building’s communication backbone and for the PACS (picture archive and communications system) used in place of X-rays. For the subsidiary lines Carter uses more economical copper cable.

Security systems have been stepped up in hospitals just as in other institutions. Carter specifies more card access systems, closed circuit television, wandering patient systems and baby abduction systems. Nurse call systems have advanced, he says, and are now interfaced with portable telephones that run on low power so that they don’t affect medical equipment.

Fire alarm systems have also become more complex. Generally new systems are addressable. These give more precise control and help to quickly identify the location of the fire. “You can interrogate every device and find out if it is functioning correctly,” says Carter.

He doesn’t like the idea of integrating too many of these systems together. “A few companies are proposing having your fire alarm, security, nurse call, building automation, etc. all on one system. Generally, I don’t think that’s a great idea and I don’t think there are really any savings because the people that are promoting it would have virtually no competition.”

On the green team

Hospitals have lagged behind other building types on the road to sustainability. Changes are coming though, notes Mike Buckley, P.Eng. of Halsall Associates, structural engineers. “Hospitals are starting — just starting mind you — to think that they should be contributing to the health of the environment if they are going to contribute to the health of the public.”

The Bridgepoint Health centre is to be a green project. The architect has taken the unusual step of asking consulting engineers Halsall and Rybka Smith Ginsler to facilitate the sustainable design approach. “Really the process is to create teamwork,” says Buckley. He believes the most successful green projects are those where the owner, architects and consultants are not in the typical descendant food chain, but treat each other as peers. When the consultants work together, each building component from the overall configuration, to the materials, to the systems can be orchestrated to have the least environmental impact.

Hospitals generate lots of nasty waste — byproducts from patient treatment, laboratories and X-ray processing. They rarely incinerate this contaminated material as they used to because of public concerns over the air emissions. Instead most hospitals ship the waste off-site for special disposal. Since this is just deflecting the problem elsewhere, environmentalists are pinning their hopes on microwave disposal technology that is being developed. Digital imaging is already helping to reduce the chemical effluents from the X-ray laboratories.

Structural engineers are regularly analyzing materials for embodied energy, and they are also helping on the green track by designing buildings to be more flexible. Buckley says that today long spans of 9-12 metres are the norm, with 30 to 40 per cent fewer columns. Thus as hospitals constantly evolve, there will be less need to demolish buildings and send waste materials to fill up landfills.

The idyllic vision

The real environmental revolution in hospitals has already taken place. The realization that a person’s physical surroundings — access to daylight, nature and activity — can promote healing and wellness has transformed their architecture. For over a decade atriums filled with daylight and lively retail spaces have been a central feature of many hospitals, offering bored patients and anxious relatives a moment’s entertainment and respite.

Playful entrances and colourful interiors are typical instead of the plain, box-like structures of former days. Ironically, as treatment becomes more dependent on technology, health buildings are being designed to look less clinical and engineered. The architects try to make them seem “friendly” and to resemble commercial and domestic buildings.

Services in the patient rooms, for example, are hidden and disguised behind wood cabinets. The lighting is soft and muted. There are no more bare lightbulbs on a plaster ceiling.

Mike Buckley recalls the “low ceilings, grey walls and green linoleum” of older hospitals, and “the window where you check in.” “That’s the kind of place that I associate with going to get sicker and sicker,” he says.

Instead, Buckley sees a new philosophy driving hospital design that is about nurturing general health and “wellness.” “The hospital in the future is no longer just a hospital,” he says. “It’s not just a place you go to check in for a procedure. It’s a place you are going to for wellness. It becomes much more of an interactive community environment. Just like when you go to the opera and you go into this wonderful building, shouldn’t you be able to go to a hospital and walk into a wonderful building simply because it’s part of your community and it’s something you should be proud of?”

Of course there’s a big difference. In an opera house patrons experience the tragedies of human life as they are presented in the perfect forms of art. The human dramas that enfold in a hospital aren’t so neatly resolved. Life for those coping with sickness is often messy and painful, fraught with frustration and boredom.

But if hospital directors, their architects and engineers can make their facilities anything like the idyllic places described in the promot
ional media packages, they will be doing human beings a great service.

There is no need to fear languishing in a gloomy institutional home when you reach old age if Marion Walsh’s vision of the future turns out to be true. Privatization, cutbacks, hoards of baby boomers soaking up the financial reserves — all concerns about the health system dissolve when Walsh describes her glowing plans for the revitalization of Riverdale: “Our goal with this and other new or renovated facilities is to create healthy buildings — smart, green buildings that include wellness design elements in colour, water features and healing gardens…. This, ladies and gentlemen, is Bridgepoint Health: an integrated village of care. Not just a cluster of buildings, but a community devoted to healthy living, a healing environment for patients and residents.”

It sounds so good, when can I book in?

All images courtesy Bridgepoint Health