Right now, there’s a flurry of acute care construction, from multistory bed towers to upgrades of aging buildings at community hospitals and academic medical centers and patient room conversions. What’s driving it?

“The luxury of replacing an entire campus is an extremely difficult financial business case to prove to your hospital’s leadership” says Sam Burnette, principal at ESa (Nashville, Tenn.).

“Owners have sunk costs in their existing campuses, which may be captive to recent $50 million to $100 million expansions and renovations. It’s difficult to abandon capital investments of that scale, with useful life, and justify funding a replacement hospital campus.”

Addressing healthcare’s aging infrastructure

Susan McDevitt, senior clinical planning principal at HDR (Seattle), says she sees two key issues driving big projects on today’s acute care campuses: aging infrastructure and growing market share.

Specifically, she says it’s hard to integrate new equipment or technology systems in decades-old buildings that don’t have the necessary ceiling heights and floor-weight capabilities to support them.

Furthermore, she says, a lot of older facilities still have semiprivate patient rooms. “In this day and age when people are shopping for healthcare, if I can go someplace that’s a little more hotel-like versus an older facility where I might have to share a room, where would I go?” McDevitt says.

Owners are also seeing the need for bigger patient and clinical rooms, including operating rooms (ORs) and emergency exam spaces, to comply with the Facility Guidelines Institute’s (FGI) Guidelines for Design and Construction and other regulatory codes, which mandate such features as larger clearances in rooms to accommodate larger equipment and spacing around patient beds.

Burnette explains that a lot of older towers were built on a 24-foot column grid, which accommodates two patient rooms within that structural span. That layout typically allows for a 11-foot-4-inch to 11-foot-6-inch clearance between the headwall and footwall in a patient room.

“Those clearances won’t meet the FGI Guidelines for current intensive care unit (ICU)  rooms and most inpatient rooms and create design challenges for larger procedural spaces such as operating rooms,” he says.

For some systems, such as UW Health, a Madison, Wis.-based academic medical center and health system, capacity issues are driving new acute care projects.

“We’re full,” says Michael McKay, director, UW Health Planning Design Construction and Real Estate (Middleton, Wis.), adding that the system was running at nearly 100 percent occupancy before the pandemic, a level that it has maintained ever since. As a result, the system is deferring a large number of patients per month. “That places pressure on us to look at where can we add beds in our system of care,” he says.

Renovation versus new healthcare construction

As healthcare organizations and their project teams set out to tackle these evolving needs on their campuses, they face choices on whether to upgrade existing facilities in place, add on, or make the most of what’s already there.

“It’s looking toward the future, thinking about that first move, and making way for potential ‘empty chairs’ to better expand and connect,” says Mark Gesinger, principal at ZGF Architects (Seattle).

As part of its Strategic Facilities System Plan, UW Health is kicking off several projects to increase capacity and flexibility for patient care, including a 101,500-square-foot module addition at UW Health University Hospital in Madison. The project is expected to begin construction this summer with substantial completion targeted for April 2026.

Another project under development and navigating final board approvals is a phased expansion at UW Health East Madison Hospital, which is currently programmed to add surgery and pre- and post-anesthesia care capacity as well as a 160-bed inpatient tower.

“If you talk to the larger tertiary and quaternary care hospitals, we’re all kind of in the same boat,” McKay says. “As rural hospitals are closing, and smaller community hospitals continue to struggle, and with the shortage of doctors, especially the specialists, more and more patients are coming to or being referred to these centers.”

Furthermore, McKay says, most healthcare and hospital systems have emerged from a period of time when many were advised to close or reduce a number of inpatient beds in anticipation of a shift in care to mainly outpatient settings.

Instead, many are facing rising patient volumes, including an aging patient population with higher acuity needs and comorbidities that require complex care and longer lengths of stay.

Coupled with organic growth in their individual markets, organizations like UW Health are moving to address the current state while preparing for future demands.

“We’re constantly in that planning mode and looking 10 years out, trying to see where these projections are going to take us,” McKay says. “Then we try to pace the construction to match.”

Replace in place projects

Burnette says he sees a lot of hospital owners building “replace in place” projects to change out small, dysfunctional spaces for taller floor-to-floor heights and wider column spacing to accommodate today’s patient rooms and procedural space needs.

The key on these projects, he says, is to phase the addition while the existing operations remain intact. Once the new construction phase is complete and services shift to the new space, project teams can modernize old wings or floors.

“We always collaborate with the owners and construction managers to phase these additions and renovations without shutting down current services. This may require working within zones as little as 3,000 to 4,000 square feet at a time to renovate,” he says.

Another challenge is figuring out where to expand services and how to tie them together with existing building layouts and operations to ensure an efficient flow of supplies and staff.

For example, during planning for the expansion of an existing bed tower at AdventHealth’s Parker, Colo., campus, the project team realized placement of the addition wouldn’t align with the hospital’s existing patient floors and clinical spaces, says Victoria Navarro, system vice president, Design and Construction Center of Excellence at AdventHealth (Altamonte Springs, Fla.).

Taking a Choosing by Advantages decision-making process with SmithGroup, the team parsed out other options on campus, deciding to move the project atop the facility’s existing loading dock and expand that structure to support a new five-story bed tower, which is expected to be completed in 2026.

“This approach is a great way to look at things without saying which is the cheapest option,” Navarro says. “We’re really making value-based decisions when we can look at certain criteria and weigh them and prioritize.”

Shifting healthcare service and space needs

While addressing construction logistics, hospital leaders are also considering what spaces are must-haves within their buildings.

Kari Thorsen, principal at ZGF Architects (Seattle), says she’s seeing a need for medical/surgical rooms that can readily adapt to future higher care levels, with larger room sizes and infrastructure for additional medical gases and lifesaving equipment.

“We try to make sure we’re giving that flexibility, so eventually we could switch or license these rooms as ICU or critical care rooms,” she says.

However, those more complex room designs come with a higher price tag and bigger space requirement, which can impact the overall size of a project.

“I think if everyone could make them future proof to license into ICU, they would,” she says. “Sometimes they’re up against budget pressures,  and they need to make some tough decisions.”

The aging population and shifting service needs are also driving space planning. “As we all know, everyone’s living longer and getting sicker,” McDevitt says. “We used to plan on an average length of stay at five days, about four or five years ago. Now it’s up to seven days.”

Among those patients, more are being assessed as Emergency Severity Index Level 3—or the catchment of patients who spend the longest time in the emergency department (ED), she says, resulting in rising ED admission rates and greater demand for inpatient beds.

A shift in traditionally complex procedures, such as advanced imaging and orthopedic surgeries, becoming less invasive or performed primarily in outpatient settings, is also impacting facility planning and design.

Because of the amount of sedation these surgical patients need or their comorbidities, this patient group falls into a 23- to 28-hour-stay category, McDevitt says.

“They’re in a little more than overnight, but we don’t want to keep them in our post-anesthesia care unit because then they bottleneck that department,” she says. “It’s trying to figure out where are some places to put them as those types of services expand within the hospital, and hopefully, as our outpatient settings grow, they can be shifted off as well.”

Future healthcare construction trends

Looking to the future, ESa’s Burnette says he expects renovations to continue and key clinical departments to be expanded.

“The market is still competitive and for elective care or your choice of ED, hospitals want that competitive edge with modernized patient units, elective procedural services, and emergency departments,” he says.

HDR’s McDevitt says the incorporation of automation and robots is on her radar as more facilities look to address staff shortages by employing technologies to handle delivery of supplies or movement of trash and linens.

Design strategies to support this adoption include having back-of-house elevators to handle throughput, space for robot charging stations, and “making sure that everything’s designed right so [the robots] can efficiently come on the floor and not have to mix too much with the staff and are separated from patients,” she says.

With an eye on clinical equipment, McKay says he’s excited by the possibility of new plug-and-play systems for major medical equipment that could ease upgrades.

“We’re starting to see the equipment finally get to the point where I won’t need to design and build a large, customized, expensive vault for each piece of equipment,” he says. “That will be huge.”

Anne DiNardo is editor-in-chief of Healthcare Design and can be reached at [email protected].

For more on acute care design trends, read “Using Design To Better Support Healthcare Staff.”