Healing in Place

Healing in Place

Some of the most disturbing images from Hurricane Sandy were those of hundreds of patients in gurneys lined up in front of ambulances in the streets of Manhattan at the peak of the storm. After New York University Langone Medical Center’s basement and elevator shafts flooded with 10 to 12 feet of water, the hospital’s electrical systems went out and several hundred patients had to be wheeled outside into the hurricane’s howling winds for transport to other facilities. The city’s flagship public hospital, Bellevue Hospital Center, flooded with 8.5 million galleons of water leading to the facility’s first extended closure since it opened in 1736. Altogether, Sandy temporarily knocked out six New York City hospitals and 26 residential care facilities, forcing the evacuation of about 6,400 patients.

A year after the hurricane, many of the metropolitan region’s hospitals are still in recovery mode. New York City Health and Hospitals Corporation recently estimated that fixing the hurricane’s damage to the city’s public hospital system and flood proofing it for future storms would cost upward of $800 million. The toolkit for storm mitigation includes new flood barriers (such as the ones installed recently at Bellevue’s loading docks), repositioning of generators, chillers, boilers, plumbing, and medical gas delivery systems. At Coney Island Hospital, administrators are even considering erecting a new, elevated building.


So why did New York City’s hospital system appear to be so woefully unprepared for Hurricane Sandy? Ironically, before the hurricane hit, Langone Medical Center was in the process of building a new energy plant, and had the hurricane happened this year rather than last year, the hospital would have been in much better shape.

However, many other hospitals in the New York metropolitan region have been slow to upgrade with resilient features. “Hospitals have been around for a long time and especially if they haven’t been updated, it is very expensive to retrofit them,” said Skidmore Owings and Merrill (SOM) Design Director Peter Van Vechten. “In the 1950s and 60s it was very common to put all of your critical mechanical equipment in the basement because it was not revenue producing and it didn’t relate directly to patient care.”

Despite the devastation, Hurricane Sandy was not in fact the first wake up call. Resiliency has been a concept in hospital design for decades. The 1994 Northridge earthquake in the state of California spurred the state’s legislators to significantly strengthen existing seismic requirements for new and existing hospitals. In 2001, Tropical Storm Allison swamped the Texas Medical Center, the largest medical complex in the country, causing losses of $1.5 billion. Then of course there was Hurricane Katrina in New Orleans, which knocked out seven of the 16 hospitals in the area for more than two years.

It appears that many of the most resilient hospital systems in the country were built as responses to major catastrophes. After Hurricane Katrina devastated a preexisting VA hospital in New Orleans, its replacement is being designed for boat access in times of flooding. After Tropical Storm Allison, The Texas Medical Center hired SOM to do a master plan that emphasizes better storm-water management through green roofs and permeable paving. Other major steps at the Texas Medical Center included getting infrastructure out of hospital basements and building a medical district energy plant above the floodplane.

However, current proposals to redesign New York City’s hospital infrastructure do not in fact envision radical changes to the status quo. New York City and New York State are proposing regulations for new hospitals and ones undergoing major renovations that would require a once-in-a-500-year storm standard and upgrades to emergency power systems. But architects say that many of the proposed regulations are already standard practice for new hospital buildings. The really critical issue is that the proposed regulations reportedly would exempt existing hospitals that were not significantly damaged from complying until 2030.

Most hospitals being built today incorporate some level of resiliency and disaster mitigation into their plans—for example, locating critical mechanical equipment above grade and building some level of redundancy into their systems. But the logjam holding up innovation is the fact that the hospitals are some of the most change adverse institutions in the country and although regulations get rewritten, frequently they are not flexible enough. “A disaster creates a new set of regulations,” said SOM Technical Director Joan Suchomel. “But because hospitals are so highly regulated, when we wish to try something new, sometimes we are fighting regulations.” One example Suchomel mentioned is the use of chilled beams, which provide more usable space than HVAC ducting and reduce energy loads. “There are places where you just cannot do that,” she said, “and whether that will change over the years is another question.”

The most storm-resilient hospitals in the country today are the so-called Defend-In-Place medical centers designed for the U.S. Veterans Administration—one area where the federal government is way ahead of the private sector. Such hospitals are intended to be the last line of medical defense after all other medical facilities go down. Designed to resist both civil unrest and national disasters, they also have extra capacity built in enabling them to accommodate patients from less well-protected hospitals. These fortress-like complexes can fully operate for five to seven days on emergency backup power and are equipped with redundant features and spaces so that they can keep operating when primary operating systems go down.


The state-of-the-art Defend-in-Place hospital coming online is the Southeast Louisiana Veterans Healthcare System’s VA Medical Center, a $995 million, 1.6 million-square-foot complex that is designed to be fully operational for seven days on emergency back up power. All of the hospital’s mission-critical functions will be located a minimum of 20 feet above grade. The hospital will have a parking garage with a roof capable of accepting army helicopters and an elevated emergency room will have a ramp that can be converted into a boat dock if the site gets flooded. In addition, the building’s exterior enclosure will be capable of resisting bomb blasts as well as 130-mile-per-hour winds.

“The unique thing about New Orleans is that the first floor is designed to be sacrificial,” said NBBJ partner Doug Parris, which is designing the hospital as part of a joint venture with New Orleans firms Eskew+Dumez+Ripple and Rozas-Ward Architects. “If New Orleans had another levy breach,” said Parris, “they could have up to 19 feet of water on the site and still have the rest of the hospital functioning.”

However, many of the resilient features at the VA hospital in New Orleans are not in fact revolutionary. Established VA standards make building in resiliency only slightly more costly than without these measures. “A lot of it is just putting the right components together,” he said. “This is stuff that they could have done a decade ago.”


Going forward, the big issue in hospital design is getting administrators to see resiliency as part of a larger picture that involves building more sustainable structures. Despite the fact that hospitals are widely acknowledged to be among the most energy intensive institutions in existence, many in the industry have been slow to incorporate LEED Hospital standards. “They want to be on board with resilience, but if they are not on board with sustainability, an important challenge is getting people to see them as the same thing.” said Robin Guenther, a principal in Perkins+Will and co-author of Sustainable Healthcare Architecture.

It is notable that despite all of its resilient features, the new VA hospital in New Orleans did not in fact manage to fully address its contribution to climate change. Although it is designed to be a LEED Silver equivalent building, and it has the capacity to recycle rainwater for non-potable uses and has a roof that was designed for solar panels, those systems were not hooked up. “All of those things were possible,” said Parris, “but because of budget constraints, we were not able to do them.”

One hospital that epitomizes a marriage of sustainable and resilient features is the Kiowa County Memorial Hospital in Greensberg, Kansas. After a 2007 tornado flattened 95 percent of the city’s downtown including a preexisting hospital, it was determined that the all city owned buildings should be built back to a LEED Platinum standard.


Kiowa County Memorial is the first 100-percent renewable energy medical facility in the United States and the first LEED Platinum Certified Critical Access Hospital. It is equipped with an onsite wind turbine that generates base power and a wind turbine farm in the countryside that supplies peak power needs. The hospital also achieves a 57 percent reduction in potable water from low flow plumbing fixtures and uses captured rainwater for non-potable uses.

However, cities with similar events often respond quite differently. “Joplin, Missouri had a set of hospitals that was notorious for being destroyed by tornadoes,” said Guenther. “They put in a facade capable of withstanding a 250-mile-per-hour wind so their mechanical equipment didn’t fly off the roof again, but they didn’t fundamentally seize the opportunity to rebuild based on the idea of renewable energy.”

A few cities aren’t waiting for their own natural disasters to develop state-of-the-art resilient hospital designs. At Spaulding Rehabilitation Hospital in Boston, Massachusetts, designed by Perkins+Will, “all of the design decisions were based on Hurricane Katrina in 2005,” said Guenther. What is striking about Spaulding, which is situated on Boston’s waterfront, is how it uses sustainable features to improve resilience. The building has a gas-fired co-generation unit that enables the hospital to produce its own electricity and its own thermal energy.

Some design features at Spaulding are revolutionary for the hospital industry, such as the decision to install key operated windows that can be raised 4 inches. Unlike in Europe, where many hospitals have operable windows, in the U.S. hospital building codes are based upon the idea that medical facilities are hermetically sealed. “Hospitals generally seal their windows because of safety concerns,” said Guenther. “But the lesson learned from Katrina was that when the air conditioning went out, people were throwing furniture through the windows because the heat was 100 degrees.”

The cost savings rational for delaying the implementation of sustainable resilient features is becoming increasingly difficult to justify. For one thing, the expense of many sustainable energy systems such as variable drives on air handlers is dropping, which should enable new hospitals as well as existing ones to better afford them. For another, many new sustainable features are increasingly viewed as dovetailing with a hospital’s mission. One example is the healing gardens, believed to improve patient outcomes, which some hospitals are installing. “If people put a green roof on their building, is it a sustainable feature or a program feature?” questioned Guenther. “They [the healing gardens] are doing two or three things—the premiums are probably a lot less than most people think.”