From ASC To Surgical Hospital

From ASC To Surgical Hospital
Is It Really Worth It? 

Transitioning an ASC to a surgical hospital is no simple task. Endless considerations abound between the two business models, and the respective facility requirements for each are no exception. John A. Marasco, AIA, NCARB, with Marasco and Associates, Inc. warns, “Do your homework first.”

“This transition certainly makes a lot of sense operationally, and sounds easy enough to accomplish, but in most cases that is anything but the truth,” he asserts. “A surgical hospital is certified and licensed by the state health department under the same requirements as a general hospital. In fact, it is considered a general hospital in most states.”

Marasco says the certification and licensure regulations for an ASC and a hospital differ vastly, and upgrading an ASC to a hospital will most likely be a big jump — as well as a big dive for the bank account. “Everything from your electrical, HVAC, and medical gas systems; to your building’s fire, smoke, and occupancy ratings, will most likely have to be upgraded,” Marasco says, and “These upgrades are no easy task.”

Sam W. Burnette, AIA, senior designer/ principal with Nashville, Tenn.-based Earl Swensson Associates, adds that another consideration is that of the facility’s occupancy type requirement will change from one category to another. This too comes with a large price tag, and a potentially even larger headache.

“You are potentially moving from a project that is a business occupancy: Type II, III, IV construction, to an institutional occupancy that’s very likely going to be a Type I or Type II facility,” he points out. “The most important thing is to do your codes research to be sure that the structure is built to the proper construction type for the conversion. For example, if it is a wood frame or lightweight steel bar joist facility without adequate fire-proofing on the steel, adequate electrical and proper ventilation requirements to convert to an institutional occupancy, then there are extensive upgrades that will be required to make this legally operable. That research of what you have today is critical before you get into planning that conversion.”

Are the conversion costs and disruptions to service more feasible than full replacement costs? “If the facility was originally constructed with the proper non-combustible structure, sprinklering, good commercial- quality electrical and mechanical systems, etc., then your conversion is very probable,” says Burnette. “But if too much was done in the cost cutting in the front end, then the results of your code research might not be good news.”

Each state typically requires certain ancillary components for a hospital which are not typically a part of an ASC, according to William R. Massingill, AIA, NCARB, chief executive officer of Polkinghorn Group Architects, Inc. These components may include a kitchen, a lab, a pharmacy room, an X-ray room, and sometimes an emergency department.

“During the design phase of an ASC project which might some day be converted into a hospital, the A/E team should design on-site spatial accommodations for these components in order for these ancillary services to be accounted for in the future without major renovations to the initially-built portion of the facility,” Massingill points out.

Growing Pains

“One of the first things we tell a client that is considering a remodel or expansion is: ‘The disruption and discomfort during construction is generally going to be worse than you think!’” says Marasco and Associates’ Todd E. Larson, AIA.

Larson says that oftentimes remodeling a facility is the best or only alternative to increasing capacity, so before you get too far down the road, a few things should be considered.

First, a complete set of accurate, as-built drawings should be obtained. “This allows you and your architect to identify and deal with the challenges of remodeling your existing facility during the design process vs. dealing with change orders by your contractor during the construction process because as-built conditions were not accurately identified.”

Secondly, a complete code analysis and review of the state’s current regulatory requirements should be completed prior to moving too far down the road. “Often times, the code and regulatory requirements have changed since you first built your facility and if substantial remodel is contemplated, you may be required to upgrade your entire facility — even those areas that you weren’t planning on remodeling. This can obviously have a big impact on both the financial and operational feasibility of the project.”

In addition, Larson points out that certain things can be done when planning the facility to help minimize any disruption and discomfort. “First, remodeling of clinical areas (e.g., operating rooms, pre-op, recovery, etc.), should be kept to a minimum. The remodeling of ancillary support areas (e.g., storage, business/administration, waiting, etc.) should be the first consideration. These areas can generally be remodeled without extensive disruption to your operations.

“Second, consideration should be given to the location of available services like medical gases, HVAC, electrical, etc. Those areas that require special services should be located as closely as possible to the existing services. As an example, if you are remodeling space for recovery beds in another area of your facility that is away from your current recovery beds, you may have a lot of disruption getting the medical gas lines piped to the new area.

“Third, the overall design of the facility should pay special attention to how phasing can occur so there is limited disruption to your operations during construction. It may look great on paper, but at some point a contractor with hammer and nails is going to be pounding away while your trying to see patients,” he adds.

Marasco offers the alternative — start anew. “For many past clients we have determined that replacing the facility all together and selling off the existing ASC is actually more cost effective than upgrading it. Have an experienced architect thoroughly examine your existing ASC and create a financial outcome study to determine your best option,” he suggests.

By William R. Massingill, AIA, NCARB, chief executive officer, Polkinghorn Group Architects, Inc.

1. Configure initial-phase PACU functions similar to pre-op in terms of per-bed size allocations and in close proximity to nurse station ‘core’ so that they can be converted into pre-op in the event that the facility is to be expanded in the future 

2. Locate nurse station, locker rooms, and sterile processing functions near ‘core’ of facility 

3. Locate procedure room functions (ORs, non-OR treatment rooms, etc.) towards perimeter of ‘core’ in order for increases in room quantities to be added away from ‘core’ 

4. Configure pre-op and PACU functions such that they can be expanded away from ‘core’ in the event that procedure room functions are expanded 

5. Initially size electrical, tel/data, and medical gas rooms large enough to perhaps accommodate some kind of future expansion of components without enlarged room sizes or secondary rooms for those services

By Sam W. Burnette, AIA, senior designer/principal, Earl Swensson Associates

1. Evaluate to determine best use of existing ORs and costly support spaces 

2. Design to minimize duplication 

3. Design ORs to adapt with changes in technology 

4. Design your pre- and post-procedural areas to flex for morning and afternoon peaks 

5. Design a separate and discreet discharge exit — this is one of the highest patient satisfiers