The New Critical Care Unit
December 17, 2013
By Steve Bjerklie
Photo by Mark Washburn
Designing and building an addition to almost any structure is always a puzzle. Just ask any homeowner who has added a room to a house. What appears to be a simple project inevitably grows into a Rubik's Cube of complications. But when the addition is to a major medical facility, Rubik himself would be challenged by the complexity.
The problem the new Critical Care Unit and the new Medical Specialties Unit (MSU), are designed to solve is simple enough: create more beds at DHMC. The need for more patient space has been a concern of Dartmouth-Hitchcock's leadership and clinical staff for several years. With a population in the Upper Valley that's growing older and thus more prone to serious health conditions, the need for more critical-care space, especially, is acute.
"The impetus has always been: Do we need to increase our capacity? And if we do, how and where?" said Gail Dahlstrom, Dartmouth-Hitchcock's vice president for Facilities Management. "But we've always known that what we really need are more critical care beds."
Yet with reimbursement models in health care changing rapidly, mapping out a strategic plan for future bed space is not a straightforward process. For example, Dahlstrom pointed out that when DHMC opened in 1993, double rooms were the norm and were generally preferred by patients who expected their hospital stays to last a week or more. They appreciated the neighborly company a double room provided. Now, with hospital stays down to just a night or three, most patients often prefer the privacy of a single room during a short stay. At the same time, the volume of cases and patients still continue to grow.
Add to those trends this fact: while there will always be a need for critical-care beds, the overall need will diminish in the Upper Valley as the baby boom generation passes on. Moreover, improvements in medical technologies and therapies are moving an increasing number of critically ill patients – who in the past would have occupied bed space – to outpatient status. "We're seeing it already in a big way with cancer patients," said Dahlstrom.
"When you think about any of these projects, you're planning for the future. The problem, though, is being visionary," said Deanna Orfanidis, administrative director for patient care in Critical Care and Surgical Services. "You have to ask: What will the patient of the future need? And who will those patients be? Where will they come from?"
It's no surprise that consideration of all these factors, and dozens more, took years. Formal discussions about a new Critical Care Unit began about four years ago, said Martha Neal Maurer, director of Clinical Support Operations, but informal discussions were held even earlier.
"There was a backlog occurring throughout the system resulting in not enough inpatient beds available to care for the demand that we were seeing. Dartmouth-Hitchcock has the highest acuity level of any hospital in New Hampshire. This meant that really sick people were not able to be seen quickly because the beds were always full," she commented. A team from the Access and Throughput committee along with Facilities and Finance were charged with writing a proposal to add 15 new Medical Specialties beds and 14 new Intensive Care beds and submitting the proposal to the New Hampshire Certificate of Need committee, which approved the proposal.
Before the architects were called to draw up blueprints, however, the location of the new Critical Care Unit had to be decided, and this became a complicated puzzle on its own. After study, it became clear that the best locations for both the new Critical Care Unit and MSU (which opened this past summer) were already occupied so that meant some departments would have to be moved, and the design and building of the new units needed to be part of the timeline for building and completing the Heater Road facility, which would house the departments – dermatology, outpatient rehabilitation, sleep disorders, etc. – that had to be moved to make way for the new Critical Care Unit and MSU. "We could not begin construction until the spaces were available. Getting to the actual construction date involved people from multiple departments pulling together data and helping to tell the story of why we needed to build more beds to take care of our patients," said Maurer.
The effort was a true team exercise. More than 135 meetings involving 120 people were held as the new units were planned, and the list of 56 departments included: (in no particular order): Lab, Lab Support, Information Systems, Clinical Information Systems, Information Systems End-User Support, Information Systems Applications Finance, Intensive Care Unit, Clinical Support, Planning & Project Management, Facilities Management, Post Anesthesia Care, Security, Revenue Management, Nursing, Operations Administration, Operational Excellence, Nursing Admin-OPN, Ambulatory, Chief Officers, Quality Assurance and Safety, Patient Placement Services, Quality Safety and Value, Clinical Engineering, Repairs and Maintenance, Communications and Marketing, Internal Transportation, Patient Flow Care, Pulmonary, DHART, Housekeeping, Pharmacy, Radiology Support Services, Linen Services, Safety and Environmental Programs, Anesthesiology, Hospital Medicine, Health Information Services, Care Management, Nursing Practice, Volunteer Services, Adult Staffing Resource Team, Financial Analysis, General Surgery, IS-Network, Human Resources Recruitment, Support Staff-OPN, Corporate Finance, Trauma Program, Telecommunications, Inpatient Med-Surg Division, ICCU, Vascular Surgery Lab, Risk Management, Cardiology, and Patient Access Services.
But deciding where to place the Critical Care Unit included much more than shuffling beds and departments. Dahlstrom explained that DHMC, though it appears to be one structure, actually comprises a series of separate buildings. Some of these distinctive buildings are obvious – the Rubin and Faulkner buildings, for example – while others are not, for example the patient towers are also one "building." Because the buildings house different kinds of patient care or medical research, each building is subject to different state, national, and international regulations regarding such basic design elements as how wide the hallways need to be and what kind and how many electrical and other plug-ins are in each room.
"Renovation projects like adding a Critical Care Unit are always more complicated than new projects," Dahlstrom added. "When you're renovating, you have to connect to existing systems. And the disruptions for construction can be very inconvenient and even costly."
After considerable discussion and study, a location adjacent to the patient towers was chosen for the new Critical Care Unit. Everyone in the projected concedes that the location isn't perfect. "The location of the new Critical Care Unit off of the mall presents a set of new challenges," said Maurer."Generally, we want to preserve patient privacy and keep patient care, delivery of services, etc., in the backstage areas of the hospital –away from public view. The new Critical Care Unit is located in one of DHMC's most public spaces – off the main mall. Much discussion was spent on how we would transport these very sick patients to other departments in the hospital without crossing the very busy mall corridor to get to the elevators." The only practical solution, though expensive, was installing a new elevator specifically for these patients in order to assure their privacy. The new elevator will take patients up to the fourth floor level and allow for transport across the bridges and hallways that our existing patients use now.
Once the location was decided on, the project moved forward in five phases: conceptual, schematic design, design development, construction documentation, and, finally, construction.
Dahlstrom said that for each phase, "it's really important to have the right people at the table." In the conceptual phase, for example, it's critical to have the full range of clinical care represented, plus leadership. In the schematic phase, where all the details of the basic design are filled in, a wide variety of specialist expertise needs to be called upon, from engineering to maintenance to telecommunications to security, plus clinical staff. "In the conceptual phase you're looking at how best to organize space to provide care," she said. "In the schematic design phase you're adding definition about the specific types of rooms and spaces you'll need. Design development, a fine-tuning phase that concludes with blueprints, follows and then comes construction.
The four design phases take anywhere from nine months to a year, said Dahlstrom – but that's after years of discussion and study of myriad factors and trends, including demographics, changes in medical therapies, changes in insurance reimbursement, and assessment of the overall health care environment, among literally dozens of other factors.
The design and stakeholder teams are justifiably proud of the new unit. (The new Critical Care Unit's many benefits for staff and patients will be described in a second article, to be published later in December in D-H Today.) But all that will be admired and seen on opening day are just a fraction of the planning, study and design. The real marvel of the new Critical Care Unit is how efficiently, economically, and deftly it solves a Rubik's Cube of challenges, trends, regulations, needs and expectations.