Case Study: Deploying an Overbuild Approach to Increase ICU Capacity & Capability A Deeper Look Health systems need to have the right capacity to meet patient demand and to enable the centralization of corresponding care units. In order to ensure optimal care quality and efficiency, organizing departmental proximities and patient flow based on acuity is critical. To this end, an overbuild expansion can help resolve capacity, organizational and urban challenges for a health system.
Increasing Cardiac Surgical ICU Capacity CHALLENGE Constrained ICU capacity and suboptimal patient flow in Robert Wood Johnson’s Core Pavilion were struggles for the health system.
SOLUTION An overbuild expansion that includes approximately 21,500 SF of new, one-story cardiac ICU space for the CORE Pavilion, additional patient transport and CSP/OR elevators, and new parking and sub-acute center transport in the adjacent South Building serve to boost capacity, improve capabilities, and enhance patient flow.
PROJECT UNDERSTANDING AND CONTEXT Robert Wood Johnson University Hospital (RWJUH), Located in New Brunswick, NJ, is an academic medical center and the flagship hospital for the RWJBarnabas Health System. The Hospital’s Core Pavilion and adjacent South Building, which house ORs and an ICU, were identified as areas in need of structural improvements. In the Core Pavilion, greater capacity to meet growing demand was integral; in the South Building, improved infrastructure was needed to enhance sub-acute center transport. Two of 17 buildings across the Hospital’s sprawling urban campus, the Core Pavilion and South Building are landlocked, requiring strategic construction methods. An overbuild approach was taken for the Core Pavilion, while risk management strategies and careful construction phasing were deployed to provide a permanent rehabilitation center transport parking lot in the South building. The permanent rehabilitation center transport lot provided stopgap parking for emergency vehicles, enabled the expansion of the Ambi building to the northeast, a concurrent project that improved front-end flow in the RWJUH ED, relieved overcrowding and modernized facilities. The primary purpose of the Core project was to vertically expand the Core Pavilion to provide adequate capacity with a 24-bed, private Intensive Care Unit in order to meet patient demand, improve care capabilities, and improve patient transport/ departmental connectivity. The project required close coordination with RWJBarnabas Construction Services, P. Agnes Inc., Stantec (interior architecture), DCC Design Group (interior design & finishes), O’Donnell & Naccarato and Highland Associates in order to determine appropriate phasing, trades logistics and construction plan.
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Design Impact: Perspective from the Field
3 Questions for Julie Arsenault Assistant Vice President of Nursing & Patient Care for Cardiology and Intensive Care Services 1. HOW DOES THE NEW ICU COMPARE TO THE OLD SPACE? Previously we were in a 10-bed, windowless unit with an adjacent open-heart recovery area. It was an antiquated, cramped space with no natural light. By comparison, the new ICU features floor-to-ceiling windows in every room—a change in atmosphere that has been life-changing for staff and patients alike.
CONDITIONS PRECEDING CONSTRUCTION Robert Wood Johnson’s Cardiac Surgical ICU capacity was 10 beds. After the overbuild expansion of the Core Pavilion, ICU capacity increased to 24 beds. In addition to the limited ICU capacity prior to the expansion, the space also lacked windows, had limited capabilities in terms accessing the patient from all sides or performing advanced procedures, and had suboptimal patient flow.
“Going from a 10-bed to a 24-bed unit has allowed patient flow to be far less restrictive than it was. We’re able to keep patients there a bit longer, and we’re easily managing the throughput and additional volume of our new surgical patients.” -Julie Arsenault, Assistant VP of Nursing and Patient Care for Cardiology and Intensive Care Services, RWJBarnabas Health
2. HOW HAS THE INCREASED CAPACITY AFFECTED YOUR TEAM? We’ve significantly expanded our capacity. We’ve gone from 10 to 24 beds, meaning we can now increase our volume, accept transfers, and add cases. We’re no longer constantly struggling with the question of whether or not we can take on new cases, which eases our day-to-day stress.
3. WHAT WAS IT LIKE FOR THE TEAM TO ADJUST TO THE NEW SPACE? We knew going from a small unit to this extraordinary new facility would mean the staff would have to adapt: A major change
Adding to the complexity of the project, the Core Pavilion was not originally designed to accommodate a vertical expansion. As the roof of the building could not be made into a floor, Array set the stage for RWJUH to go vertical via architectural design. Core and shell design also addressed the need for better patient transport throughout the facility. In its previous state, the patient elevators were smaller than modern elevators, and the facility lacked an ICU
in capacity always affects teamwork and coordination of care. But our staff has made the transition exceptionally well—as expected. The rooms are beautiful and wellequipped, which goes a long way toward making the staff happy.
elevator sized to accommodate multiple staff and medical equipment.
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case study: increasing cardiac ICU capacity | PAGE 3
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The lack of a rehabilitation center transport lot at the South
was phased in two steps allowing all below-slab plumbing and
Building resulted in an overcrowded emergency vehicle
HVAC to be installed before the new floor was poured.
parking lot near the northeast Ambi building. As drivers were waiting for sub-acute patients to complete their appointments,
SUPPLEMENTING AND ENHANCING PATIENT TRANSPORT
rehabilitation center transport vehicles were occupying critical
The four elevators within the building – two patient, and two
parking areas near the ED.
public— were replaced with modern, expanded equipment. As the new ICU was located on the third floor, a better connection
IMPLEMENTATION
between the ED, OR and ICU was needed. For that purpose, a
A two-phase project, the Core Pavilion overbuild presented many logistical challenges. By working closely with the RWJBarnabas Construction Services, Array helped to deliver a process-led design that resolved the challenges facing the organization while ensuring constructibility and collaborative excellence with other AEC and trade teams.
larger ICU elevator was installed. The larger size of the elevator allows for greater staff support and equipment capacity for when high acuity patients need it. Front and back elevator access enables better connectivity between the services on each floor, allowing for better flow and less time to move patients from point A to point B. Finding the right location to install the ICU elevator was a challenge. Array’s design
OVERCOMING CHALLENGES OF A LANDLOCKED CAMPUS
team helped identify a large air shaft situated between three
Array helped overcome the hurdles to an overbuild at RWJUH
buildings on the campus to centrally locate the transport.
by putting forward a design to reinforce existing columns and beams and incorporate an interstitial space between the existing roof and a new floor. This design resolved the limitations of the Core Pavilion’s roof. The construction process
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The elevator was then hung to allow air to continue to flow beneath it, and the new elevator shaft became part of the new lateral structural system for the building to meet seismic requirements.
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amount of it was hand dug, we had to drop in piles for the capacity. We had to find a subcontractor that had a small enough drilling rig that they could drive it through the building and get to this air shaft.” -Faith Orsini, Assistant VP of Construction Services, RWJBarnabas Health
The new South Building rehabilitation center parking lot created a new entrypoint with direct access to clinic spaces within the campus. This lot helped completely remove subacute center transport vehicles from ED-designated parking areas. Additionally, this lot provided parking for emergency vehicles during the expansion of the Ambi building and ED ambulance parking. ENHANCING EQUIPMENT INFRASTRUCTURE The design of the new Cardiac ICU space incorporates booms rather than a headwall system, allowing hospital staff to pull a patient’s bed away from the wall to access to all sides, including the head. The expanded space accommodates equipment previously too large for the facility’s cardiac spaces. On other floors of the Core Pavilion, enhancements to infrastructure allow for better operational flow. Mechanical space and exit passageway upgrades on level F allow for improved facilities management and more direct egress from the building, while new surgery storage on level one clears space for more optimal surgical department organization. KEEPING WITH THE DESIGN AESTHETIC The exterior façade of the new third floor was designed to maintain a common design aesthetic throughout the campus. Materials used include pops of glass, metal and brick to tie the new and existing elements together, allowing for one modern,
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clean and cohesive design. A FUTURE-READY SPACE With ample ICU capacity to meet demand, a more unified cardiac care department, better departmental connectivity, and improved infrastructure, Robert Wood Johnson’s expanded facility will allow them to deliver an improved patient experience and more efficient care. The project also sets the stage for RWJBarnabas to continue expanding by providing enhanced patient transport via new elevators and better infrastructure for new space arrangement opportunities with their partners at Rutgers University.
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case study: increasing cardiac ICU capacity | PAGE 5
Published: April 2019
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