Healthcare: Acute Care Renovations - March 2010

By Darius Helm

Many hospitals are old and there aren’t enough of them—that’s the basic issue facing America’s acute care business. New technologies, new approaches to healthcare and the needs of an aging population are the driving forces behind the unstoppable growth of this commercial sector, growth that should endure for decades.

It’s really a perfect storm. First of all, there are a number of pressures on the physical structure of existing hospitals. New medical procedures and devices have a direct impact on the shape and usage of the interior space. HVAC systems, increased plumbing, and electric and optic cables force changes in the dimensions of rooms. New understanding of what influence health, illness and recovery impacts not just the interior space but also the shape and size of the entire facility.

Second, there’s pressure on the basic hospital model itself. There aren’t enough rooms to accommodate the growth in patients due to the aging baby boomer population, a trend exacerbated by the shift from two-patient rooms to single-patient rooms. At the same time, outpatient procedures are increasingly common, and technologies like laparoscopic (minimally invasive) surgery reduce hospital stays, leading to the growth of clinics and other small specialty healthcare practices. These days, plenty of surgeries take place in venues other than hospitals.

Flooring’s growing role in healthcare
Flooring plays a central role in acute care design, in fact a much bigger role than it used to. Back in the 20th century, hospital flooring was first and foremost utilitarian. That meant sheet vinyl, likely neutral and speckled, everywhere from operating theaters to patient rooms, and VCT in corridors, cafeterias and back-of-house operations, with perhaps a patch of carpet here and there.

These days, just about the only flooring categories largely absent from acute care are hardwood and laminate. Sheet vinyl, along with some rubber, dominates the sterile side of facilities, and broadloom and carpet tile are increasingly used everywhere from patient corridors to lounges and reception areas. Stone and ceramic are common in lobbies and entrances.

Furthermore, flooring design plays a much bigger role. Healthcare experts now understand that color and design have a significant impact on patient outcomes, the reduction of hospital errors, the well being of hospital staff, and the profitability of healthcare institutions. Flooring manufacturers have embraced the trends, working closely with A&D firms to produce flooring that meets the specific performance and design requirements of healthcare flooring.

The growth of healthcare and its increasingly diverse floorcovering needs have led a lot of flooring manufacturers to get into the healthcare business. On the hard surface side, while traditional healthcare giants like Mannington and Armstrong have ramped up their offerings, rubber producers like Johnsonite and Nora have grown their healthcare businesses, along with vinyl tile makers like Centiva, CBC Flooring’s Toli, and Amtico. Flexco, Metroflor and Roppe also have growing healthcare businesses, as do younger firms like Halo Floors and recent entrants into the North American market like Gerflor and LG Hausys Floors.

Linoleum has also been gaining share in hospitals, thanks to issues like low VOCs, sustainable attributes and natural antibacterial qualities, led by firms like Forbo, Johnsonite and Armstrong. Even stone and ceramic producers like Crossville have been getting into the game.

On the carpet side, all of the big commercial mills now do a significant business in healthcare, both acute care and assisted living. InterfaceFlor, Shaw, Mohawk and Tandus are the biggest healthcare carpet providers. Another big player in soft surface is Mannington, which has the unique distinction of being the only firm that makes commercial carpet and vinyl (and now rubber as well)—and the firm is well known for its coordinated hard and soft surface healthcare offerings.

The acute care landscape
Broadly speaking, there are three prongs to the redesign of the acute care business—new hospitals are being built, clinics and other out patient facilities are being built, and existing hospitals are being renovated. Firms like Nebraska headquartered Leo A Daly, one of the top ten architecture and design firms in the nation, have seen their healthcare business grow significantly over the last decade.

At Leo A Daly, a privately held firm with a team of over 1,100 architecture, design, planning and engineering professionals in 30 offices worldwide, healthcare now accounts for nearly half of all its business, made up of both new hospitals and renovation work. Its projects include ongoing renovation work at facilities like the Nebraska Medical Center, as well as military sector healthcare, like DOD and VA facilities.

According to Jeff Monzu, AIA, a senior architect at Leo A Daly, military projects come with a unique set of challenges because of the heavy use of standards and guide plates that specify, among other things, room by room equipment layouts for specialized working environments according to specific departmental functions. Such standards can make things easier but at the same time can be an impediment toward adopting newer, more effective healthcare models. The challenge is to push these planning models into the 21st century.

Monzu and Kim Ferguson, ASID, AAHID, LEED AP, a senior interior designer and project manager at Leo A Daly, also point out other examples of entrenched behaviors flirting with obsolescence. One flooring related example involves maintenance. Traditionally, hospital floors have been buffed and polished to achieve a level of glare that is generally equated with a clean floor. However, it’s more perception than reality. For one thing, today’s resilient flooring, be it rubber, vinyl or linoleum, tends to be low gloss, particularly for healthcare applications, where glare can be disorienting to aging eyes. Matte finishes also hide wear and imperfections better than high gloss flooring. But even though today’s matte finish flooring is easier to maintain and keep sterile, it can still be a challenge to convince environmental service professionals to adjust their practices and ways of thinking to accommodate the product improvements.

One of the more interesting challenges involves the use of carpet in patient corridors. Noise is one of the biggest barriers to patient comfort, and an effective method of sound abatement is to switch from resilient flooring to carpet in the corridors outside patient rooms. Using carpet also offers other benefits, like comfort underfoot and a generally warmer and more comfortable atmosphere, which has been shown to directly affect both patient outcomes and staff wellbeing.

However, this approach can meet with some resistance from staff who feel that it’s a lot harder to push gurneys and equipment over carpet than over VCT and consequently feel that carpet will make work harder. Again, it can be more perception than reality, since loop carpet doesn’t provide the kind of resistance that cut pile carpet can present. In addition, firms like Leo A Daly address rollability issues by using larger casters, which effectively eliminates the problem. But there’s still the issue of convincing staff to accept the change.

Baby boomers are having a multifaceted impact on healthcare. First there’s the sheer numbers—nearly 80 million Americans between the ages of 46 and 64. According to government estimates, 20 years from now that number will only have dropped 20 million. For the next decade or so, every passing year will see significant increases in the number of people using the healthcare system, the number of people no longer able to look after themselves, the number of surgeries and emergency room visits.

In addition, baby boomers are a demanding generation with more active, engaged lifestyles. They have greater expectations of comfort, good health and active senior lifestyles than their predecessors, and they’re more involved in their healthcare. Furthermore, they’re nostalgic.

These are all issues that impact design, including flooring design. That’s what’s behind many of the trends. That’s why assisted living facilities seem like the offspring of cruise ships, and hospital lobbies the demure first cousins of hotel lobbies. And that’s why wood looks end up in patient rooms, even if it’s really vinyl. It’s about creating atmospheres that are welcoming, familiar and comforting.

One of the challenges of healthcare designers like Leo A Daly is to convince clients of the value of spaces that don’t directly generate revenue. While it’s obvious that the MRI room generates huge revenues and therefore should include topnotch features like high performance flooring in calm, blissful colors, the value of putting Italian porcelain tile in the lobby or installing lush carpet in a meditation room is harder to quantify.

While hospital administrators may have trouble understanding the value of such seemingly intangible investments, it’s a concept familiar to much of the business world: it’s marketing, branding, knowing your customers and tailoring your operation to suit them. Healthcare facilities are competing for patients, patients who want to know that the institution they choose is both warm and gentle and also wealthy and powerful beyond compare. They want a hospital with the compassion of Mother Teresa and the superstar skills of LeBron James.

That means striking a subtle balance, hitting all the right notes. It means lobbies that make a statement without being extravagant, patient rooms that are quiet and cozy and welcoming to family and friends yet discreetly crammed full of the most cutting-edge equipment, and chapels and sunlit lounges that help you forget you’re in a hospital.

According to Monzu, the recession has had a direct impact on these sorts of elements. He cites a project that was postponed at the start of the recession, about a year and a half ago, and when it recently restarted the client decided to address the tighter budget by going with VCT instead of carpet in the hospital corridors. Other clients have expressed concern about spending in lobbies and entryways, worried both about the appearance of extravagance and the value of the investment.

The Nebraska Medical Center
Leo A Daly has a special relationship with the Nebraska Medical Center, the largest healthcare facility in the state. Located in downtown Omaha, the Nebraska Medical Center is in fact the recent offspring of two hospitals that happened to be directly across the street from each other, University Hospital and Bishop Clarkson Memorial Hospital, known these days as University Tower and Clarkson Tower. Leo A Daly actually built Clarkson Tower back in the 1950s, and University Tower is even older than that.

In 1997, the two operations were merged. Soon after, Leo A Daly began work on the Hixson-Lied Center for Clinical Excellence on the street between them, joining the two. The four story operation was completed in 2005, housing emergency services, cardiology, radiology, surgery and the newborn intensive care unit.

Leo A Daly also does a lot of renovation work for the hospital, which has over 1,000 physicians on staff and treats 25,000 patients a year. The challenge has been to take buildings over 50 years old and retool them to offer state-of-the-art healthcare. To date, the firm has completed over 1,000 projects. Major renovations and expansions include a new college of nursing, a birthing center, patient unit renovations, a 637-car parking garage, a series of connecting skywalks, and the world renowned Lied Transplant Center.

Originally the towers used a lot of quarry tile, along with that classic green hospital wall tile, and though they did their job and stood the test of time, they had to be replaced. The terrazzo in the front lobbies was a different story. It, too, had survived more than half a century in excellent shape, but the color palette was outdated and difficult to work with. However, at least for now the cost of ripping up all that terrazzo and going with something more contemporary has put that project on hold.

In the Nebraska Medical Center, the operating rooms are largely epoxy floors, which provide excellent sterile conditions, though they can be tough underfoot. Sheet vinyl is used in patient rooms, with an emphasis on wood looks, as well as in some of the procedure rooms. VCT has largely been relegated to storage rooms and utilitarian spaces. Luxury vinyl tile is increasingly used for some of the applications where VCT was traditionally used, like in the emergency departments, surgery recovery areas and some corridors. The bathrooms, a far cry from the hospital bathrooms of the last century, feature porcelain tile in upscale designs reminiscent of high end hotels.

There’s very little hardwood flooring in the Nebraska Medical Center, but there are plenty of wood looks. Leo A Daly had considered using reclaimed wood in the chapel, but went instead with PermaGrain’s GenuWood, with a clear vinyl wearlayer over a real wood veneer.

Carpet is installed in patient corridors, offices, waiting areas and cafeterias. In the neonatal unit in the Hixson-Lied Center, carpet is used everywhere except procedure rooms, where the floors are rubber.

Because the medical center is a long-term client with a contractor regularly onsite, Leo A Daly has the opportunity to do test installations of various products in corridors and the like. For instance, the firm did a test installation of rubber flooring to check out its performance, maintenance characteristics and other properties, and once its value had been determined, it was installed in a patient corridor.

Among the biggest renovation challenges has been going from double occupancy rooms to single occupancy, as well as the decentralization of nurses’ stations. The decentralization not only makes the nursing staff more visible to patients but it also cuts down on noise levels. Those central staff hubs are among the biggest noisemakers in traditional hospitals.

On the roof of the Hixson-Lied Center is a rooftop garden with grass and decorative bushes and plenty of places to sit down and relax. It’s right next to the Newborn Intensive Care Unit, which features dozens of private suites for babies and their families. Like so much of the Nebraska Medical Center, the rooftop garden generates an atmosphere that calls to mind hotels, vacation resorts and spa retreats. About the only thing it doesn’t call to mind is a hospital.

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