Relocating an imaging suite could limit the transport time for extremely ill patients, but may increase shielding requirements

The competitive health care market continually is challenging facility owners and managers to upgrade, expand, and renovate their facilities to provide state-of-the-art medicine. Imaging departments tend to experience change most frequently because of constantly changing technologies and the potential for increased revenues from increased capacity. Institutions cannot build new facilities each time they change out technology, so the obvious choice is to renovate and retool existing spaces as efficiently as possible. Interior hospital renovation projects, particularly for imaging departments, demand a knowledgeable and senior design team that knows how to approach the project to help the owner obtain multiple returns with the same investment. The design team can help the owner manage costs, time, and future flexibility.

Renovating existing space to accommodate new imaging equipment can be quite complicated, especially if the building is old and has experienced multiple renovations. While each renovation project is different, owners should be aware of five strategic planning techniques that are essential for a successful and cost-effective imaging-department renovation.

Begin With Flexibility

Creating a patient-friendly environment in rooms containing high technology can be acheived through lighting, color, temperature and room size

It is critically important when planning a diagnostic imaging department, or even an individual imaging suite within a larger department, to recognize that technology will change, perhaps before the project is even completed. It is imperative to ensure that the design provides some level of flexibility to accommodate inevitable change. Flexibility in planning includes a clear zoning of diagnostic suites, equipment support, and staff support spaces within the department, as well as some generic design considerations within the actual imaging room. To acquire the latest technology possible, owners may delay the selection of an equipment vendor until later in the project when the renovation is well under way. The design obviously cannot wait until then to be completed. One approach is for the finished project to accommodate more than one equipment manufacturer's equipment. This slightly generic approach can provide the owner with flexibility in negotiating the purchase of equipment.

"The equipment becomes obsolete before the room," says Richard Sprow, AIA, associate principal, Perkins & Will, New York. "Whenever possible, we avoid designing a room specifically to accommodate only one equipment vendor's machine, and we try to never build the minimum-size room. We have frequent, detailed communications with vendors and their design staff to coordinate our design. We design floors, walls, ceilings, and lighting to accommodate varying equipment needs, such as lead and copper shielding, support structures, steel reinforcement, bored holes in concrete slabs, lighting, and various electrical services."

Designs that are customized to one particular vendor's piece of equipment have to be altered if the equipment changes, which can result in increased costs to the owner and schedule delays. Newer equipment may offer improved capabilities or efficiencies, but at the same time may have different requirements of the physical space. They may be heavier, requiring increased structural capacity; they may generate more heat, which would necessitate additional cooling; they may draw more electrical power, requiring electrical upgrades; they may require additional shielding or acoustical and vibration isolation; and they may just be larger, requiring more space either in the room, or to get the equipment into the room. All these seemingly invisible equipment changes have impacts on the design of the space.

For MRIs in particular, there are significant requirementsand limitationsfor design. For instance, within the actual magnet room there can be no ferrous metal on building materials, fixtures, and especially mobile equipment. The magnetic field is so strong that metal objects can become projectiles within the room, resulting in injury and significant damage to the room and equipment. All nonferrous metal or "MRI-compliant" materials must be used for items like stretchers, IV poles, mobile carts, and medical equipment. To effectively screen for metal items that enter the room accidentally via staff or patients, some institutions elect to install a metal detector at the door to catch any metal objects before they enter the MRI suite.

Efficiency in Planning

Managing operating costs is of prime concern to hospital administrators, and new projects should be planned so as not to require any additional FTEs to operate effectively. Imaging departments can be designed for improved efficiencies while still increasing the department's capacity and therefore revenue.  Whenever possible, imaging technologies should be grouped so they can share common support spaces such as equipment rooms, mechanical and electrical support, technician control areas, physician reading rooms, consultation rooms, and storage. Common work and support spaces can result in improved communication, coordination, and productivity within the department. A central support "core' wrapped by imaging suites may require fewer technicians to staff as well as less space than if each imaging suite had its own dedicated support spaces. Cross-trained imaging technicians can increase productivity further and reduce staffing needs. A central support space also allows for more isolated renovation and equipment upgrades of suites situated along the perimeter while operations are maintained in the rest of the department. The support spaces remain to serve the new imaging equipment.

Situating diagnostic and therapeutic imaging modalities close to other invasive procedures such as surgery has the advantages of consolidating highly specialized services, as well as minimizing transports between these services for acutely ill patients.

New York Presbyterian Hospital wanted to situate an MRI suite and a CT scanner adjacent to a neuroscience intensive care unit to adjust to today's requirements for frequent patient imaging. Bringing inpatient and outpatient imaging departments closer to surgical services also facilitates procedures in which "remote control" via imaging is part of the treatment itself, allowing procedures to be less invasive and performed in smaller spaces. This also requires less moving of critically ill patients: the technology can move to the patient versus the traditional method of transporting the patient to the technology.

"More and more, the imaging and surgery are taking place simultaneously, blurring the line between the two procedures," says Susan Niculescu, PhD, AIA, associate principal, Perkins & Will. "Although cardiology, radiology, and surgery are still separate departments, they frequently use the same equipment and need similar support spaces. For example, cardiac catheterization uses the same equipment as angiography."

Planning for the Long-Term

While nearly all imaging modalities have special physical requirements to either contain, control, or absorb energy from the imaging source, some imaging technologies, such as MRI magnets, have rigorous siting requirements due to the internal physical properties of the modality. These requirements not only specify the proximity to occupied areas, but also dictate the materials and objects that can be situated around the magnet. The space becomes highly specialized, so long-term planning is critical to future flexibility in and around the imaging suite.

Vibrations created in the building and proximity to large quantities of steel or large steel objects, such as cars or elevator cabs, can affect the functioning of the equipment. Magnets should not be situated near existing or future elevator shafts. Older buildings require a structural study to determine whether the floor needs additional support, or if there is old steel concealed and forgotten for years that may be in the environment. New structural steel has to be sized carefully and situated in order to avoid becoming magnetized and further impacting the operation of the magnet. In some cases, more magnetic shielding, in the form of heavy steel plates, is needed to contain the magnetic field within a safe area.

The placement of equipment must take into account how the equipment will be delivered to the actual room, including the doorway to the outside as well as the travel route within the building. When it is not possible to situate equipment along the exterior wall of the building and it has to be situated internally, careful consideration must be given to the transport route within the facility. Some imaging equipment is delivered to the site assembled in large pieces, which have to be transported carefully through the facility's corridors and doorways and put in place on whatever floor the department is situated. For these large, heavy-equipment items, such as magnets, the travel route through the building has to be studied carefully to accommodate the size of the equipment as well as support it. Sometimes, supports have to be added below the corridor floor to ensure the equipment is supported along its transport route. Also, designers sometimes provide space, such as a hatch in the roof, for future replacement of equipment.

Another consideration is the technology itself. For example, the all-around Gauss  field of the imaging equipment itself, once it is operational, affects other technologies in nearby departments. In some cases, the equipment has to be shielded above and below. For one New York Presbyterian MRI suite renovation, situated between a surgical department above and a cardiology department below, the designers had to strengthen the floor and shield the MRI equipment with special solid-steel sheets in addition to the copper and lead shielding already in place.

ReValidating Existing Conditions

Particularly when renovating imaging departments, it is important to revalidate the actual existing conditions once selective demotion has been completed, especially in older buildings. While record drawings may be available to document previous renovations, in very old buildings, these records may not be available to provide some guidance as to existing conditions. Even when drawings are available showing previous reconstruction work, the precise locations of objects hidden behind walls, above ceilings, and below floors may be dramatically different than originally intended. Much of the cost of renovation projects depends on knowing precisely where things are and what it costs to interface with them. During renovation projects, costs can escalate dramatically with these "unforeseen conditions." Traditionally on renovation projects, the contractor performs the required demolition, and if there are any unforeseen conditions or conflicts, the designers are alerted via a Request for Information. The designers study the situation, possibly visit the site, and provide a solution back to the contractor. The contractor reviews the situation and may have more questions before reaching a solution. This process can take considerable time, and may cause project delays and cost increases.

To be more proactive and minimize the impacts of unforeseen conditions, it can be very useful to have the architects and engineers, along with the contractor, perform a postdemolition revalidation of the design.  Once substantial demolition is complete, the design team, including the respective subcontractors, can inspect the demolition site in order to see the raw, exposed spaces and measure, inspect, and validate that the design works within the space. Seeing the exposed spaces allows the design team to uncover any unforeseen conditions or conflicts immediately so they can begin to resolve them and/or adjust the design. Having the contractor present during this postdemolition site inspection allows the designers and builders to collaborate on how to resolve conflicts immediately. It is essential to double-check that all plans will work, especially in older facilities where the dimension requirements can be as tight as just a few inches.

Patient-Friendly Environments

Like many aspects of today's modern health care, imaging environments still can appear intimidating to patients. For as long as this technology has been around, architects and designers have been seeking ways to make these high-technology environments feel less imposing, warmer, and more comforting. The challenge continues to lie in the physical limitations imposed by some imaging technologies.

Various design innovations have been implemented successfully to improve the appearance and character of the imaging environment. Situating equipment in larger rooms may make the technology seem smaller. Temperature should be controlled in each room. Using soft lighting to highlight artwork or murals on walls and ceilings is a technique used to suggest openness and the idea of windows and skylights. Architectural coves with indirect lighting, warm-colored materials, and textures help to humanize the environment. Small changes that seem merely aesthetic can have a huge impact on the space. Sound systems can be designed to allow for customization to the individual patient's music selection. With the right lighting and design, even a windowless environment can be made to feel welcoming and foster a feeling of wellness.

When owners, managers, architects, and designers agree on the key strategies outlined above, the results drive higher revenues and lower costs in imaging department renovations.

Chris Bormann, AIA, Perkins & Will, New York City, can be reached at chris.bormann@perkinswill.com.