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Designing A Disaster-Proof Hospital

Hospital design is evolving to withstand worsening storms and rising tides.

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All it took was two feet of water to debilitate the Veterans Administration Hospital in New Orleans in the wake of Hurricane Katrina.

Once the flooding infiltrated the basement-level windows, it destroyed the emergency generators that the entire hospital depended on after municipal power cut out. Life support systems, lights, and heating and cooling were knocked out. At Memorial Hospital, also in New Orleans, an even more dire situation arose involving power failure, the inability to sustain patients in intensive care, and building evacuation. Forty people died there as a result of the storm, igniting a medical ethics debate about how to handle patients in disaster situations. (A doctor and two nurses were arrested for expediting the deaths of four patients; they were not convicted and the charges were expunged.)

Now, more than 10 years after Katrina hit, the Southeast Louisiana Veterans Healthcare System is celebrating the grand opening of its new hospital, a 1.7-million-square-foot facility designed by NBBJ that embodies the lessons of Katrina.

The Architecture Of Resilience

Hospitals are a literal lifeline and in the aftermath of a natural disaster. They become even more indispensable as places to treat its existing patients, admit people who were hurt as a result of the disaster, and provide emergency relief to their respective communities. The should not fail in times of crisis.

Hurricane Katrina laid bare the structural deficiencies and vulnerabilities of medical centers. In the New Orleans area, 7 of 16 hospitals with acute care centers remained closed two years after the storm. Architects tasked with rebuilding the facilities were posed with a critical challenge: rebuild the hospitals so that in the event of a similar, or even stronger, storm, the buildings remain fully functional and self-sufficient for days on end.

"It’s unfortunate, but right now the maps where we draw the extent of vulnerable areas are expanding, and areas that weren’t considered vulnerable before, are," Ryan Hullinger, a principal at NBBJ, says. "These techniques are going to be needed in more and more hospitals."

The new hospital is considered a "mission-critical facility" by the VA, meaning that it needs to survive and stay operational in nearly any type of disaster: natural, like a hurricane or earthquake, or man-made, like a blast. Structurally, the perimeter can withstand category three storms and the walls are hardened to resist blasts, ballistic assaults, and ramming. Moreover, the building's bones are designed to guard against progressive collapse—meaning that if one part of the building is destroyed, it won't cause a domino effect and lead to a full collapse.

Building the hospital "upside down" is another key resiliency strategy, which is also the core conceit of hospitals under construction in New York. (NBBJ first experimented with this tactic about 10 years ago when it began construction of the Ashley Tower at the Medical University of South Carolina.) Instead of placing all of the operational essentials—like power generators, the power system that connects to the municipal grid, and the emergency room—in the basement and ground floor, they're elevated. The emergency room is on the second floor and vehicles access it via a ramp that also doubles as a boat launch if floor waters impede access—a useful move for getting people to the hospital and evacuating the building, if necessary, which was a problem in the old building. (A helicopter landing pad on the roof of the adjacent parking structure can also help with accessing the hospital.) All of the power systems are on the fourth floor and fill lines for the generator's underground 32,000-gallon fuel tank are also elevated above the 500-year-flood line, so they can be accessed during high waters.

If a disaster strikes, the building can remain fully operational for five days. A 6,000-square-foot on-site warehouse holds food and water for 1,000 people to get through the days. Additionally, a rainwater catchment system on the roof mitigates runoff and feeds into underground tanks for a backup water supply. All of the patient rooms can convert from single to double occupancy in case the hospital needs to serve as an emergency shelter.

"This is a poster child for resiliency," Doug Parris, the project manager and a partner at NBBJ, says.

For Veterans, By Veterans

In addition to the resiliency challenge, architects at NBBJ also were also tasked with designing for a very specific population—military veterans—which have different needs from civilians. The hospital serves more than 70,000 veterans in the region. To understand what would be needed from the new facility, the architects conducted interviews with more than 100 veterans and nearly 200 staff; they also hosted 21 workshops to form and refine concepts; and spent 75 hours observing patients. Since the hospital was an entirely new build, NBBJ could reengineer virtually every part of the experience, from circulation to layout and patient journeys.

"It’s a unique culture with unique hopes and aspirations," Hullinger says.

Patients at the hospital come from the New Orleans metropolitan area as well as from outlying rural areas. To better understand what the veterans wanted, NBBJ traveled to the neighborhoods and areas where they lived and interviewed them in informal settings to strike up a rapport and really get to know them. During evaluative sessions, NBBJ took notes on what the veterans wanted to see. Then the architects created renderings and mock-ups of concepts based on the interview content. Next they presented the ideas back to the same groups, to ensure that nothing was lost in translation.

"We wanted to make sure there wasn't a disconnect between what we heard, the implications, and how that informs the space," Hullinger says.

Compared to the civilian population, veterans are more likely to have physical disabilities, limited mobility, higher obesity rates, and auditory challenges. Additionally, there are mental health considerations, like PTSD, depression, and sexual assault in female veterans, that come to bear in the design. For example, the colors in the building deliberately avoid the hues typically used in the military, like army green, gray, and sand. During one of the workshops the designers presented a textile whose pattern reminded some of the veterans of barbed wire.

"We didn’t see it, but they did and that was very informative," Parris says. Another design move? Ensuring that there was no bamboo—a popular plant to use in humid climates like in New Orleans—in the gardens, which could potentially be a PTSD trigger. "That’s one of the nice things about being able to talk with the veterans there. Even with existing research, some things aren't readily apparent."

Hypervigilance was another theme to emerge from NBBJ's human-centered research. "Veterans were once in threatening environments and they’re always looking at where the doors are and the means of escape from this position," Hullinger says. "These reflexes don’t always go away when they return to civilian life, so designing spaces that put the veteran at ease was a big driver."

Prospect and refuge theory—an environmental psychology concept that explains why people seek spaces that let them observe while remaining secluded—influenced this angle. "We needed to design were the veteran could see out in open spaces and feel like they aren’t being seen," Hullinger says. For example, the staircases don't have any switchbacks so people using them don't feel like their back is turned. The waiting rooms are on the perimeter of the structure, near windows. The architects also worked to ensure there weren't any tight spaces or dark corners.

"The veterans [we interviewed] often expected less than they deserve and they do deserve a building that is supporting of their physical, emotional, and spiritual needs," Hullinger says.

Borrowing From Hospitality And Office Design

To design spaces that exceeded expectations, NBBJ borrowed from other disciplines, like hospitality and corporate office design, to inform patient experience and workflow for the doctors and nurses, respectively. "We were looking to instill a sense of dignity and civil importance that honored [the veterans'] sacrifices," Hullinger says. "It was about making them feel appreciated as soon as they entered the hospital."

The arrival sequence was heavily influenced by hotel design. "Some drive two hours to get here and understanding their needs when they first got there was important," Parris says. "Do they need transportation assistance? Is there a concierge waiting for them? Is there a bathroom nearby? The second they arrive on campus, they are greeted in a way that expresses their needs."

The architects also specified finishes that are natural and warm—like wood wall cladding and slate-gray floor tile—which are the antithesis of typical antiseptic hospital materials. Furniture needed to be extra stable, sturdy, and have dimensions that could accommodate all bodies and ability levels. Another big difference between veterans and civilians is the social aspect of being in a hospital. Civilians keep to themselves and their families, but NBBJ found that the veterans liked to swap stories and converse, which also came to bear on the design.

"Camaraderie and getting to know each other, what was your experience, that sense of storytelling was important to them," Hullinger says. "Seating arrangements that are supportive of conversations were important. Then you have to be inclusive of someone of a wheelchair so they can pull up into a social circle."

Courtyards outside provide space for both patients and staff to go for fresh air and also help instill lightness and openness on the campus so the structure doesn't feel like a big box.

The layout of the in-patient floors also affects the patient-provider experience. Typical hospital floors are arranged like a racetrack with a nurses' station in the center and patient rooms along the perimeter. The VA's floors have patient rooms flanking a core dedicated to staff. Borrowing from corporate workspaces, NBBJ divided the area into areas for specific types of work: collaborative; quiet, focused work; and also space for families. To further refine workflow, nurses and doctors communicate via a wireless system instead of through noisy pages over an intercom system. "That’s all tied to the emerging understanding of a nurse as a knowledge worker that can benefit from the techniques of Silicon Valley," Hullinger says.

All told, the VA Hospital embodies the idea that a resilient structure should not compromise on safety, patient experience, or the ability for providers to offer the best care.

"If you design simply based on criteria, either storm resilience and the requirements for hurricanes and projectiles potentially flying though the air, that is one area," Hullinger says. "Then you overlay that with the detailed requirements based on security and blast protection, you could easily end up with a building that’s a bunker and not welcoming and soul stirring. That’s where the design becomes interesting."

[All Photos: via NBBJ]

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