Surges in hospitalizations, such as those experienced with COVID-19, put health systems at risk. Operating over capacity makes it difficult for hospitals to provide care to patients in a timely manner and may also delay carrying out elective surgeries.

During the early days of the COVID-19 pandemic, we saw hospitals and governments mobilize to meet access challenges, erecting temporary facilities in parking lots and moving some patients to off-site quarantines. But bed shortages are also a concern during annual flu seasons, with many hospitals running near capacity during the winter months, sometimes resulting in the need for facilities to divert ambulances, set up temporary tents, or boost staff levels to deal with the overload of flu patients.

In early 2016, Cedars-Sinai Medical Center in Los Angeles realized the need to rapidly add beds to avoid shortages that fall. Thanks to an inventive, two-increment process, Cedars-Sinai and design firm Leo A Daly (Los Angeles) managed to convert an existing 29-bed rehabilitation department into an inpatient unit to meet the short-term crunch, while simultaneously working toward a comprehensive, code-compliant renovation of the unit.

As health systems seek ways to cope with fluctuating infectious disease rates, the story of Cedars-Sinai’s 7th Floor South West (7SW) renovation offers a model for meeting capacity needs in the short and long terms.

Challenge and opportunity
Looking at historical data and Centers for Disease Control and Prevention (CDC) projections for the 2016-2017 flu season, Cedars-Sinai anticipated a shortfall in the 886-bed hospital’s inpatient capacity. In times of normal demand, the hospital had already been experiencing higher-than-usual utilization rates. Without expanding, leaders were concerned they wouldn’t be able to handle an influx of flu patients in fall 2016.

Administrators eyed a future vacancy on the seventh floor of the southwest quadrant of its main hospital tower—a 29-bed rehabilitation unit that was scheduled to relocate to the nearby California Rehabilitation Institute in July 2016. Although outdated and lacking in some infrastructural elements, such as accessible patient rooms, the space offered sufficient square footage (14,526 square feet) to add five more beds. The unit was also a good candidate because it already had headwalls, giving it the medical gas connections needed to function as a medical/surgical unit.

After identifying the space, the next step was to work with the authority having jurisdiction, the Office of Statewide Health Planning and Development (OSHPD), and the licensing body, California Department of Public Health (CDPH), to approve the change of use. Leo A Daly held a preliminary meeting with OSHPD in March 2016 to gauge the feasibility of gaining occupancy by the fall with only minor changes to the physical space.

OSHPD suggested using an incremental work plan, which breaks a project down into several milestone phases where occupancy is obtained at the end of each phase rather than waiting for approval of the entire project. For 7SW, a two-increment work approach would mean that Leo A Daly would conduct a thorough code review to identify the minor adjustments that would be necessary to begin receiving patients by fall 2016 while also documenting the deficiencies that would need to be addressed later. Then, once the unit was operational, the second phase would add five code-required accessible patient rooms, including two isolation patient rooms, along with additional storage, a staff bathroom, and patient gurney alcove. These spaces would be carved out of rehab activity rooms no longer needed in the new medical/surgical unit.

Increment 2 was given a head start by the fact that the same design team was already in the construction documents phase of a similar med/surg unit renovation across campus (called 6 North) and could use that prototype design, including patient rooms, nurses’ stations, finishes, and lighting, to accelerate user approval for the 7SW project.

The project team submitted the code review in May 2016, and OSHPD approved the plan. With OSHPD’s recommendation, Cedars-Sinai held a separate discussion with CDPH to obtain concurrent approval with the request of a program flex, because the licensing body has the authority to grant flexibility in how the hospital meets the intent of licensing regulations. Cedars-Sinai provided a letter to OSHPD and CDPH to guarantee that the fully code-compliant renovation would be done following initial occupancy.

Increment 1: Rapid occupancy
Before occupancy could be granted for Increment 1, the unit’s air balance had to be tweaked to meet the pressure relationship and ventilation requirements of the 2016 California Building Standards Code. Leo A Daly also requested testing of the unit’s water purity, polarity, nurse call system, and fire alarm in order to provide a fully functional environment for inpatient care.

OSHPD and CDPH were in regular contact with each other and with Cedars-Sinai to identify and establish priorities for every project on campus. Communication with inspectors and adequate preparation at all stages of the application helped to push the project along in the licensing process.

The unit obtained licensing approval in September 2016 and was immediately put into operation. The 29 additional beds helped alleviate demands for acute care services during the 2016-17 and 2017-18 flu seasons, the latter of which was the highest since the 2019 H1N1 pandemic.

Increment 2: Code-compliant modernization
Design for the second phase of the project got underway as soon as Increment 1 was approved by OSHPD, with design elements from the 6 North project integrated. The renovation adds five patient rooms, bringing the unit total to 34. The ADA-compliant patient rooms are larger than the existing patient rooms, with new technology, upgraded headwalls, larger windows, patient-controlled LED lighting, laminate finishes, and casework. In patient bathrooms, tempered glass and large format tiles are used to cut down on grout lines, enabling easier cleaning and providing a strong visual aesthetic.

Two rooms are designed as negative-pressure isolation rooms with anterooms for treating highly infectious patients. Casework in the patient rooms and anterooms are designed to increase the efficiency of environmental services, nurses, and materials management staff by allowing them to access clean and soiled linen and trash without entering patient rooms.

Construction was completed in 24 months, while the new unit was in full operation. Disruption had to be minimized, requiring close work with contractors and nursing staff to maintain cleanliness and minimize noise impacting adjacent patient rooms. All noisy construction work was coordinated during the day, infection control barriers were provided, and patient rooms located next to the construction area were left empty to reduce noise transfer to other rooms.

The unit began receiving patients in January 2019. Most recently, the isolation rooms were used to help Cedars-Sinai meet the growing needs for patient care during the COVID-19 pandemic.

Broad application
Incremental projects have always been used to enable staged occupancy for major or complex projects, but 7SW shows that small projects can utilize this approach, too. In this case, the approach helped accelerate the project to meet an immediate need while a full renovation was designed.

Most hospitals deal with flu season annually, and as COVID-19 rages, hospitals are now more mindful of the need to plan for pandemic events. As more hospitals move outpatient services off-campus and critical hospital space is freed up, incremental projects like the one for Cedars-Sinai may help facilities find room to accommodate potential surges or increased patient care needs. But a med/surg unit is only one place where an incremental project approach makes sense. This approach can be applied to any part of a hospital, especially in areas where it’s critical to keep downtime to a minimum, including pharmacies, laboratories, patient support spaces, and new buildings.

As more facilities identify the need to prepare for the next patient surge related to a flu season or pandemic, the incremental project approach can be a critical part of their tool kit.

Robert D. Counter, AIA, is senior associate, director of healthcare at Leo A Daly (Los Angeles). He can be reached at Gerard Gulpeo, AIA, is associate, project director at Leo A Daly (Los Angeles). He can be reached at Linda Tan, AIA, LEED AP, is senior architect, facilities planning, design and construction at Cedars-Sinai (Los Angeles). She can be reached at Pamela Goff is senior interior designer at Leo A Daly (Los Angeles). She can be reached at