SOUTHERN DISTRICT HEALTH BOARD FEASIBILITY STUDY

Transcription

1 SOUTHERN DISTRICT HEALTH BOARD FEASIBILITY STUDY UTILISATION OF BEDS IN DUNEDIN HOSPITAL WARD BLOCK 6 SEPTEMBER 2016

2 Prepared for SOUTHERN DISTRICT HEALTH BOARD Document Revision Status Revision 1.0 Date: 6 September 2016 DRAFT for comment Document Control Prepared by Architect Jonathan Rae CONTTS 01. DESCRIPTION EXECUTIVE SUMMARY BUILDING FORM BED STUDY RE-LIFE METHODOLOGY APPDICES 11 Reviewed by Project Architect Jonathan Rae Approved by Principal or Director Phil Grey On behalf of Warren and Mahoney Architects Limited Disclaimer While Warren and Mahoney has endeavoured to summarise the Preliminary Design process in this document and appendices, the report format cannot represent the broad range and depth of information captured on the Preliminary Design Drawings, Specifications and Schedules. Approval of the specific issues contained in this report does not discharge the obligation of the client team to review the drawings and specifications in their entirety. Contact CUMBERLAND STREET. CLINICAL SERVICES BUILDING ONCOLOGY CTRE. Warren and Mahoney Architects Ltd E.D. DAY SURGERY 254 Montreal Street Christchurch 8013 T: E: wam@wam.co.nz WARD BLOCK CONCOURSE. CHILDR'S PAVILION. LECTURE THEATRES. ADMINISTRATION BUILDING 2

3 01. DESCRIPTION This study examines the suitability of the Dunedin Hospital ward tower for re-lifing as the potential inpatient component adjunct to a new clinical services building. It does this by firstly analysing the form of the existing building and examines some precedents for shape and size. It then looks at what typical ward can be achieved within the footprint and compares this with some precedents. Finally it looks at what the broad strategy and timeline for implementation might be and what impacts that has. 02. EXECUTIVE SUMMARY Examining the re-lifing from the three broad categories of form, clinical function and physical implementation FORM While the tee shape is not ideal from the point of view of horizontal evacuation in a fire and the location of the cross over between back of house functions and public functions in the junction of the tee it is possible to make a functioning layout between the Clinics and an inpatient unit consisting of two wards and associated support spaces. The floor to floor height, apart from a few local beams, is generally the same height as modern ward accommodation and will allow ceiling heights of 2700mm generally with some localised at 3000mm. The building grid does pose some limitations on possible layouts as the new standard of four bed room encroaches across the zone that is currently allowed for circulation, and coupled with the relatively narrow centre grid creates a requirement for a single corridor arrangement rather than a racetrack. Additionally it causes the current fire escape stair and risers to impede a potential ward layout so that at least one but preferably both of these features would be moved to the outside of the existing floor plate. Finally the length of the perimeter restricts the number of possible bed rooms, with a limit to single beds of two 24 bed wards. In this configuration no other parts of the ward have access to the window wall. BED STUDY The application of standard ward layouts shows that the maximum size ward that can be achieved is 30 beds in a 2 ward inpatient unit per floor arrangement that has a ratio of 47% singles (14 patients in Single rooms and 16 patients in 4 bed rooms). 28 beds would allow for a higher ratio of single rooms at 57% singles (16 single and 12 patients in 4 bed bays) To allow this arrangement to work with the revised single corridor administration and shared support areas need to be brought to the centre junction of the tee block. The advantage to this is better distinction between on and off stage functions while the disadvantage is longer travel times for staff. Because of the constricted area at the junction of the Tee and the need to cross over public and service flows at this point this is not as fully possible as with a new build option. This arrangement would also need to re-arrange the circulation core area for shared visitor and staff amenities however would not encroach into the clinics area, which is too far away to be useful in any case. IMPLEMTATION The two timeline diagrams summarise the thinking behind relifing the building. This strategy is reliant on additional external plant risers and stairs to be constructed to facilitate maintaining the existing floors as operational while work takes place, and as the existing service ducts are inadequate in size for modern demands, particularly for separation of extract for isolation rooms. As can be seen from the diagram the construction period is likely to be extensive, about 8 years in total, if the only small sections can be made available at once in order to keep the hospital operating. The assumption of two wards, one clinic and a lobby area at once (effectively a floor in total) is not unreasonable. Creating the spare space in the ward block relies on the completion of the new CSB or other building to house the population of the wards and clinics being worked on. The building timeline shows the effect of the extended time frame and discusses some of the other costs to a prolonged renewal project. If it starts after the completion of a new CSB it could realistically be 15 years before the completion of the final element of refurbishment. To make the degree of refurbishment worthwhile a reasonably long target lifespan would be needed at which point the underlying structure would be relatively old- at the start of its new life this is 50 years old, the default structural life specified in the Building Code. Due to the prolonged timespan and complicated movements if re-lifing the ward block was to be pursued further we would recommend that: A structural engineer is employed to evaluate the existing condition of the concrete structure and precast panels and what extent of treatment and recladding is needed to protect them for the proposed future life. A construction programmer look in further detail at the programme of works and its feasibility to enable a quantity surveyor to factor this into any cost based analysis. This should include the costs of decant and recant required. That a serious attempt is made to quantify the cost to the health board in terms of staff time, disruption and inefficiency so that this can be included in any cost based analysis. That the functional adjacencies of re-use in this location are compared with those achieved by any new build. It may or may not be possible to put a cost on not optimising them IN CONCLUSION It is possible to create a new ward environment within the existing ward block with inpatient units based on per ward. This will require extensive work including new areas outside the existing footprint and extend over a prolonged length of time. The duration will cause negative effects of its own on the whole organisation and these need to be included when analysing the various options. Additionally there are costs and complications to an extended refurbishment programme that need to be factored in when comparing with any new build. The real determinant of whether the re-lifing is viable need to be the underlying reasons as to why it is being done, such as the current building is in the correct adjacency or the need to spread the cost over a number of years for example. This is critical to getting a realistic result out of an options appraisal, particularly against a new build option. APPDICES 3

4 DB.7/1 Ward 7c 730 S BUILDING FORM BASIC SHAPE The building is constructed in a T shape with the long head of the T continuous and currently containing patient ward functions- hereafter referred to as Wards section and the body of the T containing Vertical circulation and clinic space. (Refer figure 2). The clinic leg of the T contains the main vertical circulation for the building and also the arrival point for the connection to the current clinical services building. The brief suggests that this area remains as clinics however connection to a new clinical services building would likely come from the opposite side. The implications of this will be investigated in the re-life methodology section. PERIMETER LGTH The perimeter divides into approximately room size units (depending on how the end is divided) where a room is an AHFG standard single bed room of in width. Refer to figure 4. STRUCTURAL SYSTEM The building is a moment frame resisting in the longitudinal and transverse directions. The Ward area and the Clinic area are separated by a movement joint. In the Traverse direction there are larger frames with deeper beams at the end external walls and in the middle of the ward section, see Floor to Floor for implications. STRUCTURAL GRID The structural grid parallel to the short axis of the building alternates between 6.68m and 7.6m wide while parallel to the long axis is circa 9m from the perimeter to the central columns and 5.48m between the central columns Corridor Service Zone This configuration suits the size of modern single rooms as a single room with en-suite plus a corridor fits between the perimeter and central columns. Because there is not a second column in the bed room zone the rooms can cope with the perimeter columns being roughly but not exactly multiples of two single rooms wide. This is also compensated for by the multi beds being slightly narrower than two rooms. A multiple of two rooms wide is the common grid spacing forward towers used almost universally in the comparator projects. Where the tower was on top of a podium or contained intensive clinical space the spacing of the grid becomes larger, such as for Christchurch Hospital. This configuration does not suite the depth of a modern four bed room however as a four bed room and en-suite almost reaches the inner column (refer Figure 1). While the depth of the building generally is similar the most comparable modern example at Taranaki extends the floor out of the basic grid at the four bed rooms allowing a straight corridor and compact service spaces in the smaller central grid. This is also the case at Middlemore. The new Christchurch Hospital Acute services building deals with this by having a larger grid and then infilling the internal space for a deeper floor plan. FLOOR TO FLOOR HEIGHT The floor to floor height generally is 4200mm which is consistent with modern development for a ward function allowing 2700mm ceilings generally and 3000mm ceiling locally (procedure rooms and similar). It is compromised by extra low beams to the braced frames in the centre section of the T making passing of services into or across the area difficult and generally resulting is ceilings being lowered to 2400mm. Functions in this area will not meet the AHFG room heights. This is clearly visible in the current building by visiting the ICU area. DUCTS AND STAIRS There are two large central ducts serving either end of the ward section of building the full with of the central grid as well as a fire escape stair at either end. These currently set the location of the corridors to suit single and not four bed rooms. The ducts in particular restrict the access area of the floor space and the stairs restrict access to the ends. Both stairs and ducts are surrounded by concrete block walls that are not part of the main structure of the building (see structural system above) and could potentially be moved and filled in to provide floor space. Currently the walls provide fire rating and hold up the stairs. BASIC FLOOR FIRE PLAN The floor layout has been discussed with fire engineers currently undertaking other works for ICU in the building. A more modern theoretical layout would often utilise a square divided into four to support progressive horizontal evacuation more extensively. AREA OF THE WARD SECTION The building breaks down in the areas shown in figure 2. This gives 2218m2 for the Ward section if the Escape stairs and main central duct are omitted. SUMMARY OF BUILDING FORM The building has a limit due to the size of its perimeter to the number of single rooms that can be accommodated at approximately 48. At this number there is no available perimeter for other functions that require access to windows and daylight. The main structure could support re-use for smaller and single rooms however the necessity for multi bed wards causes some conflict without modifying the structure. Comparable modern New Zealand projects extend this extra size outside a grid of similar size to the ward building. In the Ward building without CLINICS/ACADEMIC BOH SHARED FOH SHARED WARD WARD Impedes Layout Badly MAIN SPACES DIAGRAM extension larger rooms move inward across the current corridor necessitating less efficient central areas for support services. The presence of the main service risers and the stairs across the full width of the central grid exacerbate the issues with larger rooms on the perimeter wall as they dictate the current location of the corridors. This compromises the entry and shared zones of the wards and the ability to plan the larger rooms. The concrete walls surrounding the stairs, ducts and lifts is independent of the main structure of the building making it possible to re-provide these in another location and fill in the floor to assist with planning an updated ward layout. The structure is a braced frame on the ends and central bay. Currently only the locations of these braces compromises the effective floor to floor heights within the structure that otherwise is comparable with modern practice. Move is Possible FIGURE 1 4P Ideally the plan will be divided in three sections, the clinic/ circulation section and two inpatient sections with each having access to the other without going through the third space to facilitate progressive horizontal evacuation and each containing a fire escape stair at the outboard ends. This can be achieved by dividing the ward footplate into two sections. FIGURE 2 4

5 SB9 SB10 SB11 SB12 SB13 SB14 SB15 SB16 SB17 SB18 SB19 S5 The structure by the T shape, location of access lifts, and low central beams implies the division into two units, one at either end in terms of fire strategy, access, and servicing. It is also understood that the current service lifts are too small and it is likely given the age of the building that in a re-lifing the mechanical parts would be replaced. The suggested remedial for this is to create new vertical circulation associated with any new connection to the clinical services building. As suggested above the building does not physically preclude re-use however there are some sub-optimal items. To be most efficient in terms of area and delivery of services ideally some modifications will be necessary. The suggested modifications that would make the floor area more usable are; 1. Moving the stairs outboard with new construction and filling in the stair location. 2. Erecting new service risers outboard next to the junction of the T and potentially with the stairs at either end to allow replacement and in filling of the central duct. 3. Potentially localised extension of the floor plate to accommodate the larger size These are being investigated by a trial fit of the ward function in the bed study section but the purpose is to have sufficient floor area within the ward to facilitate the adjacency of the ward support spaces to the ward rooms. Currently this shows the location of the existing stairs and ducts causing inefficiencies in the layout requiring them to be moved. As noted in the re-lifing methodology there are other benefits to moving the ducts. INTERNAL COLUMN GRID SPACING PERIMETER DIVISION BY SINGLE BEDROOMS FIGURE 3 FIGURE APPDICES 5

6 04. BED STUDY This section looks at the trends in bed provision, potential layouts and comparison of the final unit of recently completed hospitals. MIX OF ROOMS UTILISED IN OPTIONS. SINGLE, DOUBLE, FOUR AND OTHER MULTI BED VARIATIONS Room mix tends to vary with the project. The trend has been towards increasing the proportion of single rooms to reduce HAIs, improve privacy, improve rest and patient experience. The new Glasgow Queen Elizabeth II University Hospital is essentially 100% single beds for standard adult inpatient units, in line with NHS Scotland guidelines presumption of 100% for new build unless there is a clinical reason to do otherwise, however the Midland Metropolitan Hospital currently under construction for Sandwell and West Birmingham Acute Services NHS Trust is 50% single, 50% 4 bed bays to facilitate social interaction. These four bed bays are also divisible into specials if required at the expense of 2 beds. The AHFG recommend the use of single and four bed rooms, with the mix to be determined for the facility in question. It is not so enthusiastic about the use of two bed rooms, essentially a widened four bed room divided in half, as it sees them as not offering the advantages of a single while also not facilitating fully the social interaction and observation that are the desirable attributes of a four bed bay. Additionally each inpatient unit should provide for accessible and bariatric patients as well as isolation. It should be noted however that current New Zealand Elderly/Recovery Services type wards tend to have an increased number of two bed rooms and singles. Two be rooms are also common in Europe but the NHS again favours the single/four bed bay mixture. CHRISTCHURCH HOSPITAL LINEAR MULTI-BED This is a unique development for the new Christchurch hospital that attempts to combine the observation, staffing and social advantages of multi-bed rooms with the privacy advantages of single rooms. Beds in this arrangement can be closed off from one another with screens and curtains or opened up for good observation and company. Wards with this unit are 25% single, 50% Linear Multi-bed, and 25% four bed rooms. This gives 75% single type beds counting the Linear Multi-bed as a single. Note this balance can be altered for specialist wards such as Oncology listed in the table below. The other Christchurch Hospital innovation within some of the wards is that the character of the four bed areas can be changed with the incorporation of a directly observing nurse base to a step down level of care just below HDU. BCHMARKING The table below compares the balance of single rooms to multi bed rooms in some more recent local and international hospitals. These were chosen based on being relatively recent, availability of information, and restricted to general medicine and surgery wards. Information on geriatric and recovery ward information is also available. Overall the trend is for Hospitals to have an increasing amount of single rooms with a mix of between 50% and 80% single bed rooms the most common to allow for some spaces with better social or passive observation problems. Typically four beds making up General medical/surgical wards while two beds are favoured for rehabilitation wards, as is occurring at Burwood Hospital in Christchurch which is a mix of 100% single and 47%single/53% double rooms wards (on plans reviewed). For the purposes of this study a generic medical/surgery ward is called for therefore a mix of single and four bed rooms will be utilised Refer table below left for bed configurations. EXISTING WARD BEDROOM PROVISION Counting rooms on level 4 and level 7 of the existing ward tower layout that could be used for one or four beds gives a total of 62 (68) to 74 beds per floor divided between three units. For Level 4 the ratio of single to total beds is 17/74 or 19%. Generally the four beds are undersized and the layout of the bathrooms is not consistent with good access for assistance. It is now also common practice to allow one toilet/shower en-suite and one toilet only en-suite for use when the shower is in use. The single bed rooms are close to standard size albeit slightly narrow however there does not appear to be specific provision for the special rooms (bariatric and Independent accessible) that are larger, or for type N-isolation that has a lobby (Refer Figure 5). THE GERIC WARD The study is based on the application of a generic template to the building. This has been derived from the AHFG along with reviewing the contents of Christchurch ASB and Taranaki wards that both use a pair of wards per floor to create an inpatient unit. The inpatient unit utilises the principle of clustering to PROJECT M2/BED SINGLE (%) MULTI-BED (%) EXISTING LAYOUT DIAGRAM Project Maunga General Bed - 47 Christchurch Womens Ward A Gynae Bed - 48 Manukau Surgery Centre Surgery Ward Bed - 75 CLINICS/ACADEMIC BOH SHARED FOH SHARED Christchurch ASB Surgery Ward % Multi-Linear Bed 4-Bed - 25 WARD A Christchurch ASB Oncology 50-25% Multi-Linear Bed Sunshine Coast University Hospital Gold Coast Unversity Hospital 4-Bed - 25 Med/Surgical Ward Surgery WARD B WARD C Difficulty Accessing A For F.O.H DB.7/4 Evacuation Difficulty Accessing A For B.O.H University Hospital Birmingham General Not Known 45 4-Bed - 55 Midland Metropolitan General Not Known for PPP 50 4-Bed - 50 Glasgow QEII General (Audit) Not Known for PPP 100 Only some special units (ICU, SCBU, L1 etc) and Paediatrics Maastad Hospital General Not Known FIGURE 5 3 WARD UNITS 6

7 PROJECTED LAYOUTS Neighbourhood HUB (Shared Space) IPU Staff Support Areas Func. Support Areas Clinic Accommodation CLINIC/ ACADEMIC Public Vert. Circ. Clinical Vert. Circ. Public Neighbourhood Hub Function IPU The building form suggests a layout for the inpatient unit by floor on the principle of two core ward areas at either end with shared functions in between. This also suits the shared support areas and where these don t fit and can be shared by floor to be located in the circulation end of the clinic leg. The projected layouts also assume that new stairs will constructed and relocated to the end as well as the ultimate removal of the large central service ducts by the refurbishment programme. These are discussed further in the Re-Life Methodology section later. The reason for this is the stairs and ducts interfere with the relocated circulation space caused by the greater depth of modern four bed rooms. TEST FIT: 100% SINGLE ROOMS The perimeter of the building provides a constraint on the number of single rooms possible, with a maximum of two 24 bed wards at 100% single. The consequences of this room balance are; Bed and Bed Support Patient and Patient Support IPU shared patient areas -Whanau Lounge -Treatment -WT -BTC Bed and Bed Support Little to no external wall remaining for other functions such as lounges, whanau rooms, social space or for amenity value for corridors to access daylight. Wards meet each other in the middle Low number of beds per floor/high area per bed (see table). FIGURE 6 NEIGHBOURHOOD HUB MODEL Central column area can be used for support functions No shared room on perimeter between wards Long travel distance within ward share support by floor. It identifies a core of ward space as core patient space (beds, en-suites etc.) and core support (nurse base, dirty utility, etc.) with shared support and patient rooms for the ward areas between. The shared patient areas have some rooms that can be customised to develop ward specialties. These relationships are represented in the Figure 6 adjacency diagram. For any arrangement of wards on the floor it is assumed that there will be shared spaces between the two wards. These may vary to allow for some specialisation between the different wards. These are rooms such as procedure rooms, therapy/gym spaces, shared assisted bathroom, ADL etc. It is also assumed that some ward functions like ward clerk would be shared and that back of house support functions would be co-located by floor centrally not interspersed with the patient bedrooms. Some general support areas such as meeting rooms and staff lockers that can be shared by floor with the clinics. It is anticipated that by clustering support a greater distinction can be made between the wards on-stage and off stage functions thereby improving patient and staff experience. An example of how this might work is shown on the heart space of the Christchurch Wards drawings attached in the appendix. FEATURES OF THE GERIC INPATIT SCHEDULE The generic inpatient unit consists of a pair of wards and associated support spaces. The full unit schedule is located in the Appendix. Notable features are: There are two wards per inpatient unit and one inpatient unit per floor Bedrooms are either single, single special, or four bed bays The single rooms are scheduled to contain one type N isolation room, one independent accessible room and one Bariatric room per ward. Nursing is provided from a work room, staff base and satellite staff base The length of the footprint necessitates 2 Dirty utilities per ward. Ward clerk and reception is identified as a shared function along with the ward administration offices There is provision for a shared procedure room, large rehab space, and assisted bathroom. For infection control a cleaner s cupboard is included in each ward area and the shared areas. Removes patient spaces with social interaction and passive observation WARD TYPE NO. OF BEDS AREA (M2) RATIO COMMT Dunedin - Ward area with a 32- bed ward: Dunedin - Maximum number of singles at 100% single: Area/Bed ratio recent Wards giving number of beds Maximum feasible number in Ward at 47% single (16 in 4-person and 14 singles) 12 4-person, 16 single bed room (57% single) 64 (2x32) Tested - Support areas do not fit in adequate proximity to core areas, therefore ratio does not accurately reflect ward actual use. 48 (2x24) Worked out backwards from floor area ratio that was midway in the benchmark range of wards 60 (2x30) Two single rooms deleted from a 32- bed Ward. 47% single falls just below the range common in modern hospitals 56 (2x28) Alternate ward, 1a 4-person room deleted from 32. This provides a higher ratio of single rooms at 57%, within the modern range. APPDICES 7

8 Ward 7a 710 S7 DB.7/3 DB.7/3 Ward 7a 710 S7 DB.7/3 DB.7/3 TEST FIT: 32 BED WARDS An attempt was made to lay out the ideal ward with 32 beds as this is a multiple of 4x 8 bed nursing units that is commonly utilised in modern hospitals. Regardless of the mix of single and four person rooms this showed: Insufficient external wall for areas like lounges or to provide amenity to central areas Four bed rooms disrupt the use of central column areas Insufficient area in the ward ends for sufficient core ward support space such as utility rooms and equipment alcoves Excessive travel to ward amenities such as lounges and whanau rooms that were displaced to the shared zone Excessive travel to utility spaces that were displaced to the shared zone. 32-BED WARD New escape stair 4P 4P 4P TEST FIT: 30 BED WARDS The maximum size of a ward that can be realistically fit in the building is 30 beds (tbc), consisting of 16 beds in 4 bed rooms and 14 singles giving 47% single beds. Clearly a two bed further reduction would make this easier if the desired ward number was smaller and would facilitate a higher ratio of single rooms by allowing a four bed bay to be omitted instead of singles. This gives a 28 bed ward with a 57% ratio of single rooms. NOTE: This allows space for a lounge/whanau room within a reasonable travel distance for each ward. This allows some window wall for lounges, family rooms and circulation to improve amenity. Not a multiple of 4x 8 bed nursing units that is commonly utilised. 30-BED WARD New escape stair 4P 4P 4P 4P CONSEQUCES OF BED LAYOUTS FLOOR AREA If we take the area of the building dedicated to wards and compare with the table (figure ) we see that at 32 beds per ward the ratio of area per bed matches the most efficient benchmarked unit (refer Appendix and table 1). What characterises that unit is that the envelope is moved in and out to maximise the efficiency of the floor plate. It also has a lowest amount of amenity and shared space with bath, procedure and staff amenities only. It is therefore not surprising that without the benefit of adjusting the envelope this quantity of beds proved difficult to fit. We can also see that the bed to area ratio for Dunedin starts to move towards the middle of the range as identified in the table below. OFFICES This arrangement assumes that no provision is made for office space at the wards not directly associated with the ward (for example charge nurse manager, ward clerk and work room offices are included, offices for specialist consultants are not). It assumes that offices and administration for specialist departments will either be with the specialist clinics in the clinic tower or provided separately in an administration area. SHARED SPACES Shared services such as meeting/training rooms, staff amenities, lockers, disposal holds, and public toilets will need to be located in a neighbourhood hub in the lift area and shared with the clinics. DISTRIBUTED ROOMS The long footprint of the building suggest two smaller dirty utilities per ward unit and ideally some nurse sub-base areas. This will assist with keeping travel distances with dirty items to an acceptable level FOUR BED ROOMS AND A SPECIAL ROOM TYPE The standard four bed is not divisible into two two-bed rooms or two singles as it is too narrow. This is due to shared circulation at the end of the opposite beds halving its requirements. For reference the standard room layouts are included in the appendix. For future flexibility a room the same width as two singles would be utilised but the space is not available. To facilitate the use of the central space within the unit from a single corridor we have also utilised a four bed room based on the corner access English NHS P21 standard rooms layout. Not using this room creates a problem with utilising the central space in the unit and displaces the clinical work room towards the shared area. 4P 4P 128m² 128m² TOTAL GERIC BED POTTIAL STUDY BRIEFING FLOORS LG G TOTAL Support Clinic/Academic NICU ICU Support Clinic/Academic Paeds HDU TOTAL GERIC BED POTTIAL STUDY BRIEFING FLOORS - 57% SINGLE LG G TOTAL Support Clinic/Academic NICU ICU Support Clinic/Academic Paeds HDU This distributes the inpatient units within the ward tower as shown in the section schematics above. 8

9 SUMMARY OF BEDS AND WARD LAYOUTS. An inpatient unit with a more modern balance can be created in the straight section of the Dunedin hospital ward block. It will contain two ward units and shared spaces between with only directly ward related administration and staff spaces. Each ward unit could contain 28 to 30 beds. This gives the ward tower a potential configuration of generic wards of 60 beds over 6 floors for a total of 360. (A low target number at 28 beds per ward give 56 beds per floor on 8 floors for a total of 336). Refurbishment to achieve the inpatient unit relies on moving the escape stair and ducts. The refurbishment and sharing of functions should also provide an opportunity to create a more on stage/ off stage split between visitor/patient and support functions however this is limited by the tee shape. CSB DECANT MIGRATION CSB DECANT MIGRATION CSB LINK & VERTICAL CIRCULATION W3 W5 W7 W11 W13 W15 W1 W9 REMOVE E W4 W6 W8 W12 W14 W16 W2 W10 DUCTS L2 L3 L4 L6 L7 L8 L9 L1 L5 G DECANT C2 C3 C4 C6 C7 C8 C9 C1 C5 GROUND EXTERNAL DUCTS, STAIRS, LIFTS VELOPE E AND STRUCTURE R SERVICES UPGRADES CSB COMPLETE YEAR 0 YEAR 1 YEAR 2 YEAR 3 YEAR 4 YEAR 5 YEAR 6 YEAR 8 RELIFE COMPLETE RYEAR 7 FIGURE 7 APPDICES 9

10 05. RE-LIFE METHODOLOGY BLOCK BUILDING TIME LINE This section looks at the approach to re-life the ward block including scope, strategy for undertaking the work, timeframe and implications of a prolonged programme of refurbishment. SCOPE OF REFURBISHMT TIME A projected timeline diagram is included and discussed later. This shows that the building structure will be approximately 50 years old at the conclusion of the re-life. The extent of work to the structure and cladding itself will to some extent be determined by the desired life beyond this date however for the study this is assumed to be 25 years after the conclusion of the refurbishment, however there will be an optimum design life for return on expenditure that will need to be studied. INTERNAL LAYOUT The internal layout for all the floors briefed for the bed study would be completely rebuilt and refurbished to accommodate a revised ward layout and model of care. The alterations necessary for this reconfiguration and the renewal of services will likely effect the other floors served for some degree of refurbishment, as will the optimisation of service locations between new and existing buildings. Additionally the fit out for these areas is already well used. It is therefore reasonable to expect these floors to all be extensively refurbished as well. LIFTS AND STAIRS The service/bed lifts are reported as being undersize. Additionally the equipment will be dated. There is the opportunity along with the connection new to a new clinical services building. These may partially replace some of the core in the exiting building, after which the shafts could be utilised as ducts or filled in for additional shared space. VELOPE AND STRUCTURE As discussed in the timeline structure below some treatment of the exposed concrete structure and cladding is likely to be necessary. Additionally any required earthquake strengthening would be undertaken. If re-lifing is a realistic possibility it is recommended a structural engineer is commissioned to examine strengthening and remaining panel and structure life to determine what level of intervention is required to achieve the desired building life. FIRE AND ACCESSIBILITY Refurbishment triggers the need to upgrade accessibility and means of escape from fire compliance as near as reasonably practical. With extensive alterations to layout upgrade to these items is likely to occur. Additionally fire safety systems will need upgrading as a consequence. SERVICES To achieve the desired life the services will need to be extensively refurbished and some additional ones added for compliance. FIGURE8 New services are likely required to deal with smoke, and while the existing ducting in itself is in good condition dampers. Additionally adding correctly complying isolation rooms to each ward will require new ducts as has been revealed during the ICU refurbishment. The supply systems mains of some other services such as steam and hot and cold water would also need to be evaluated and potentially replaced. It is likely that at the same time the earthquake bracing of services systems would be improved to match the Importance Level of the building. STRATEGY FOR REFURBISHMT The most rapid method for re-furbishing the ward building would be if a wing of the T could be made available from top to bottom as all of the servicing for the building runs vertically and this avoids problems with restricted access to the ceiling spaces of the floor below for drainage works and access to service risers. It is unlikely that this would be possible and still enable the hospital to function for the duration of the refurbishment as it would require a large amount of decant space. As the hospital is serviced by wing vertically rather than by floor the approach to re-life the building is suggested as many of the floors as can be made available by vertically by wings two at a time one above the other. It is likely to take nine months to upgrade a pair of wards above each other at a time. (We have based this on the construction time for ward refurbishment and extensions to Parkside at Christchurch Hospital). In the clinics wing it is assumed that one floor can be made available at a time, with two months for decant and six months for construction allowed for a total of eight. From the structure analysis and bed study it is likely that some additional area will be required, or at least removal of obstacles within the main floor plate. Additionally it will be necessary to replace some services and add new ones and the current ducts are both full and will be required to be maintained for the floors yet to undergo refurbishment. Replacing services within the existing ducts will lead to multiple disruptive shutdowns for the existing hospital floors. For these reasons it is suggested that new services risers are constructed outside the existing floor plate designed for the revised configuration at the start of the project along with installation of new plant. At the end of the project or as they become empty the duct space in the centre of the existing floor space could be filled in either fully or partially and utilised as clinical space, alleviating the entry pinch point. Along with the risers plant may be installed by floor in some instances to assist with flexibility. The interaction of these times can be seen in the project construction timeline The access and lift area of the clinic wing potentially will need adjusting to suit any new connection from the clinical services building. At its most minimal this would involve connecting in however as it is on the other side there is the potential to mirror the service and public connections which may release some usable area from circulation and improve the onstage/offstage split. This would be facilitated by including new service lifts with the CSB connection, at the same time allowing size issues to be addressed. The likely sequence is laid out below and represented on the construction timeline. 1. Construct additional areas at either end. This is as a 10

11 minimum the staircase and new external service risers but potentially ends of four bed wards if this proves viable. Ideally at this stage the CSB connection and new vertical circulation would also be constructed. 2. Install new vertical services into new service risers 3. Commission new lifts 4. In pairs vertically up the first wing of the T refurbish the generic wards. 5. In pairs vertically up the second wing of the T refurbish the generic wards. 6. Fill in old ducts and refurbish locally. 7. In parallel refurbish the shared and circulation space within the clinics block 8. In parallel if sufficient decant space is available, refurbish the Clinics wing, otherwise this needs to follow the reconfiguration of the entry and the ward spaces. This is assuming that works on the clinic area can be run concurrently by creating sufficient decant space in the new CSB. It also assumes of the four wards currently identified as moving out that there are two for refurbishment and two to make up the numbers in beds while the refurbishment is being undertaken as they have lower bed numbers than the final ward. (Being potentially NICU/Paediatrics and ICU/HDU). See Figure 7 for Construction Programme Diagram. IMPLICATIONS OF CONSTRUCTION AND TRANSITION PROGRAMME The refurbishment of the wards will take time, and this needs to be coupled with the time to design and construct the new Hospital Clinical Services Building before any work starts on the ward block. For the purposes of this we are assuming that a new clinical services building is 7 years away (3 years to confirm content and design, 3 years to build, 1 year commissioning and migration). These two timelines, the life of building timeline and the construction programme have implications for the Dunedin Hospital site. See Figure 8 for Construction Programme Diagram. LIFE OF PREVIOUSLY REFURBISHED WARDS AND DEPARTMTS As shown on the diagram the recently and currently being refurbished departments will have expended between 13 and 17 years of life at the conclusion of the Ward block refurbishment. Significantly of these projects only the First Floor has had its windows replaced. LIFE OF THE STRUCTURE AND EXTERNAL VELOPE CONCRETE FRAME AND CONCRETE CLADDING PANELS The refurbishment Timeline diagram shows the expended life of the structure. For reference this places the structure beyond the 50 years NZBC design life for elements contributing to structural stability. Elements of the main frame and cladding are exposed concrete, for which the treatment is unknown. As concrete is subject to migration of chlorides over time causing decay of reinforcing it is recommended that a structural engineer is commissioned to look at the remaining life of the structure, panels and panel fixings. Depending on the outcome of these investigations options for extending the life of the frame range from treating the concrete with chemicals to halt chloride migration only through to fully over-cladding with a systems such as Aluminium faced phenolic panel. For an extension of 25 years treatment and upgrade or over-cladding is likely. With the extent of the works proposed demonstration of compliance for H1 as reasonably practical upgrade of the insulation/thermal performance would be desirable. 10th 9th 8th 7th 6th 5th 4th 3rd 2nd ACADEMIC SOUTH WING Plant room MS3 south Clinics Gastroenterology Clinics Clinics Clinics Clinics Clinics Clinics WINDOWS The current windows provide inadequate solar control and poor insulation. The hardware is also old, as are the seals and gaskets. These are being partially remediated for the current works however the life is not being extended nor replacement made. Observations from undertaking this work indicate that for a worthwhile extension of life and for building consent upgrades to meet H1 the windows will require replacing. These were replaced on the refurbishment of NICU/PAEDs for acoustic reasons, and depending on where the Helipad is moved in the new project acoustic upgrades of some existing facades may also be required. COSTS OF DECANT PROGRAMME MONETARY COSTS OF MOVING With each move there is a cost to decant and move departments about, temporary works for screening, signage and decant, and setup work on each floor. These become disproportionately large with smaller movements and as can be seen from the construction timeline there are movements for both the clinic and wards within the tower. Extra staff may be required to organise the decanting and deal with the disruption. Additionally throughout the construction programme the hospital will not have its designed adjacencies so will be less efficient. NURSING 11 HIGH ACUITY (ExICO) NORTH WING 11 HIGH ACUITY (Ex HDU) ONGOING NOISE AND DISRUPTION Keeping the hospital going means that some of the construction noise and disruption will need to be tolerated over a period of eight years. Additionally to mitigate disruption some techniques may not be able to be use or may be restricted in time (e.g. Impact drilling of structure) as they transmit some distance through the building. This generates additional stress for staff and patients which will be over a prolonged period of time. HEALTH IMPACTS Studies in America show an increase in airborne contaminants associated with construction work in hospitals. While steps can be taken to limit this it cannot be eliminated altogetherparticularly for partial floor refurbishment. Coupled with noise and disruption to rest and sleep there is potential to impact health outcomes although this is extremely difficult to quantify. It should be noted that the disruption is both during the CSB construction period and the Ward block refurbishment so may be for a period of eleven years. LOGISTICS OF PLANT SPACE The need to run new services and keep the old ones going for a period at the same time is likely to lead to at least a period of time where servicing the building is much more expensive than running either the new systems or the old. Additionally the layout of the new plant may be compromised by the need to keep existing plant operating. ALIGNMT TO MODEL OF CARE AND CLINICAL ADJACCIES Throughout the construction programme the hospital will not have its designed adjacencies so will be less efficient. Additionally it may not be possible to achieve complete alignment with the desired functional adjacencies or model of care within the existing building leading to the compromise being carried forward over the life of the ward block. FORMER CLINICAL SERVICES BUILDING SITE At these ages refurbishment of these floors will likely be required shortly after completion of the Ward Tower re-life. Lecture Theatre 1st Clinics CHILDR S PATIT WARD NICU Used to be Confirmed Grd Used to be Confirmed USE TO BE CONFIRMED USE TO BE CONFIRMED FIGURE 9 LG Used to be Confirmed USE TO BE CONFIRMED USE TO BE CONFIRMED APPDICES 11

12 06. APPDICES 01. SCHEDULE OF AREA 02. AHFG BED ROOM LAYOUTS 03. COMPARISON TABLE COMPARATOR PLANS 10 12

13 Dunedin Hospital Ward Block Bed Utilisation Study Schedule of Areas 47% Single 30 Bed Theo (3) 9/09/2016 Dunedin Hospital Ward Block Bed Utilisation Study Schedule of Areas 47% Single 30 Bed Theo (3) 9/09/2016 AHFG Room Code Inpatient Unit, 30 Bed, 47% Single Room/Space Number Size m 2 Remarks Patient Areas 4BR-ST Patient Room, 4P base size 1BR-ST Patient Room, Patient Room,, Special, Bariatric Patient Room,, Special, Independent accessible This size assumes no stay over divan for family. This may be unsound and m2 for all rooms may be a safer assumption 1BR-IS-N Patient Room, Special,, type N Consider PPVL for flexibility ANRM Ante room S-ST En-suite, std S-ACC En-suite, Accessible For Isolation and Accessible room S-BA En-suite, Bariatric Bathroom Shared per floor?moved to shared Toilet, Patient, Acc Additional to En-suites. 1 near day room. Sub total Discounted circulation 35% Increased from 32% for existing building and single rooms Total, Patient Rooms, 14 Support areas Day room/dining 1 15 Note. Operational policy discussion re- whanau room 15.0 in addition or together. INTF interview room Here or shared? SSTN-14 Staff Station,14m SSTN-5 Staff Station,5m Centralised included Office, Clinical workroom WCST Toilet, Staff 3m Bay, PTS Adjacent POCT and SStn Bay, POCT Or Meds/CU. Define policy BLIN Bay, Linen, Clean Assumes trolley rotation model BLIN Bay, Linen, Dirty Assumes trolley rotation model BRES Bay, Resus Trolley BMEQ-4 Bay, Mobile Equipment Number tbc BBEV-OP Bay, Beverage BMT-4 Bay, Meal Trolley size tbc with trolley size. BHWS-B Bay, Handwash at each entry, 2 at SS, Additional to rooms BHWS-PPE Bay - Handwash/PPE At class S segregation rooms tbc CLUR-14 Utility, Clean Medication Room currently excluded and in CU DTUR-12 Utility, Dirty Smaller may work best STEQ-20 Store, Equipment Size required TBC STGN-9 Store - General, 9m Store Moved to shared and reduced to 1 Photocopy/Stationary, 8m2 STPS-8 CLRM-5 Cleaner Sub-total Discounted Circulation 32% Ward size Ward Shared Spaces Room/Space Number Size m2 Remarks Public WCPU-3 Toilet, visitor In lift core area. Toilet/Shower 0.0? ASB provide next to whanau room WCAC Toilet, Accessible 1 6 Distance from core to end of unit likely too 6.0 great, not currently in core LNPF-20 family/whanau lounge * Bay, public telephone 0.0? Clinical Areas TRMT Treatment room ** Allied health Space INTF interview room BATH bathroom Staff Areas MEET-L-20 Meeting Room PROP-2 Property bay-staff SRM-15 Staff Room, 25m Includes a beverage bay.nb SRM-15 is for ward WCST Toilet-Staff,3m Toilet-Shwr-Staff, 5m Staff Station, Ward Cerk for both, * OFF-S9 Office,, 9m Nurse manager, SMO 1 of each/ward OFF-3P Office - Three Person Shared, 15m locate to facilitate re-use as clinic in specialist 30.0 ward. Office approach TBC OFF-2P Office - Two Person Shared, 12m office approach tbc Support Spaces DISP-10 Disposal Hold STPS-8 Store- Photocopy/Stationary, 8m STGN-9 Store, General CLRM-5 Clnr may be in core sub total discounted circulation 32% Plant Air handling 1 15 Due to extra unit and existing duct space separate intake is likely to be required for at 15.0 least on pod on the floor Comms Switch cupboards Use existing, not measured in available area 25.5 Total Shared Areas Total Unit area * Additional space per ASB over AHFG. Requirement depends on operational policies ** Extra over AHFG to facilitate use of trolleys/beds (sim. ASB) 7521_SDHB Dunedin Wards Outline SOA.xlsx 1of2 7521_SDHB Dunedin Wards Outline SOA.xlsx 2of2 13

14 Dunedin Hospital Ward Block Bed Utilisation Study Schedule of Areas 57% Single 30 Bed Theo (4) 9/09/2016 Dunedin Hospital Ward Block Bed Utilisation Study Schedule of Areas 57% Single 30 Bed Theo (4) 9/09/2016 AHFG Room Code Inpatient Unit, 30 Bed, 57% Single Room/Space Number Size m 2 Remarks Patient Areas 4BR-ST Patient Room, 4P base size 1BR-ST Patient Room, Patient Room,, Special, Bariatric Patient Room,, Special, Independent accessible This size assumes no stay over divan for family. This may be unsound and m2 for all rooms may be a safer assumption 1BR-IS-N Patient Room, Special,, type N Consider PPVL for flexibility ANRM Ante room S-ST En-suite, std S-ACC En-suite, Accessible For Isolation and Accessible room S-BA En-suite, Bariatric Bathroom Shared per floor?moved to shared Toilet, Patient, Acc Additional to En-suites. 1 near day room. Sub total Discounted circulation 35% Increased from 32% for existing building and single rooms Total, Patient Rooms, 16 Support areas Day room/dining 1 15 Note. Operational policy discussion re- whanau room 15.0 in addition or together. INTF interview room Here or shared? SSTN-14 Staff Station,14m SSTN-5 Staff Station,5m Centralised included Office, Clinical workroom WCST Toilet, Staff 3m Bay, PTS Adjacent POCT and SStn Bay, POCT Or Meds/CU. Define policy BLIN Bay, Linen, Clean Assumes trolley rotation model BLIN Bay, Linen, Dirty Assumes trolley rotation model BRES Bay, Resus Trolley BMEQ-4 Bay, Mobile Equipment Number tbc BBEV-OP Bay, Beverage BMT-4 Bay, Meal Trolley size tbc with trolley size. BHWS-B Bay, Handwash at each entry, 2 at SS, Additional to rooms BHWS-PPE Bay - Handwash/PPE At class S segregation rooms tbc CLUR-14 Utility, Clean Medication Room currently excluded and in CU DTUR-12 Utility, Dirty Smaller may work best STEQ-20 Store, Equipment Size required TBC STGN-9 Store - General, 9m Store Moved to shared and reduced to 1 Photocopy/Stationary, 8m2 STPS-8 CLRM-5 Cleaner Sub-total Discounted Circulation 32% Ward size Ward Shared Spaces Room/Space Number Size m2 Remarks Public WCPU-3 Toilet, visitor In lift core area. Toilet/Shower 0.0? ASB provide next to whanau room WCAC Toilet, Accessible 1 6 Distance from core to end of unit likely too 6.0 great, not currently in core LNPF-20 family/whanau lounge * Bay, public telephone 0.0? Clinical Areas TRMT Treatment room ** Allied health Space INTF interview room BATH bathroom Staff Areas MEET-L-20 Meeting Room PROP-2 Property bay-staff SRM-15 Staff Room, 25m Includes a beverage bay.nb SRM-15 is for ward WCST Toilet-Staff,3m Toilet-Shwr-Staff, 5m Staff Station, Ward Cerk for both, * OFF-S9 Office,, 9m Nurse manager, SMO 1 of each/ward OFF-3P Office - Three Person Shared, 15m locate to facilitate re-use as clinic in specialist 30.0 ward. Office approach TBC OFF-2P Office - Two Person Shared, 12m office approach tbc Support Spaces DISP-10 Disposal Hold STPS-8 Store- Photocopy/Stationary, 8m STGN-9 Store, General CLRM-5 Clnr may be in core sub total discounted circulation 32% Plant Air handling 1 15 Due to extra unit and existing duct space separate intake is likely to be required for at 15.0 least on pod on the floor Comms Switch cupboards Use existing, not measured in available area 25.5 Total Shared Areas Total Unit area * Additional space per ASB over AHFG. Requirement depends on operational policies ** Extra over AHFG to facilitate use of trolleys/beds (sim. ASB) 7521_SDHB Dunedin Wards Outline SOA.xlsx 1of2 7521_SDHB Dunedin Wards Outline SOA.xlsx 2of2 14

15 AUSTRALASIAN HFG STANDARD COMPONTS AUSTRALASIAN HFG STANDARD COMPONTS This document is for advisory purpose only This document is for advisory purpose only 15

16 ProCure21 + Reducing the cost of construction through standardisation REPEATABLE ROOMS CATALOGUE ProCure21 + Reducing the cost of construction through standardisation REPEATABLE ROOMS CATALOGUE Four-bed Multi-Bed Bay with en-suite and separate en-suite WC Description Traditional arrangement with reduced bay footprint, observation of three out of four beds from the corridor, reduced distances to en-suites, and space for artwork Bedroom NIA 61.3sqm En-suite NIA 6.3sqm En-suite WC NIA 1.9sqm Corridor run 7400mm IPS 1.8sqm Three arrangements of this repeatable design are available to suit local choice, with each using the same standard components and each being functionally compliant with the relevant HBN and Design Manual requirements. Comparison table Bed area nia En-suite sh/wc nia WC nia Design manual sqm 6.5sqm 2.0sqm Traditional layout Diamond layout T form layout 61.3sqm 58.5sqm 58.4sqm 6.3sqm 1.9sqm 6.3sqm 1.9sqm 6.3sqm 1.9sqm Corridor length 7700mm 7400mm 2800mm 11150mm Views out (equiv. total window size) Head to head distance Not stated 3900 x mm (3 windows) 3600mm 3600 x 2000 (MBB corner location) mm 4700 x 2000 (2 corner windows) mm Observation from corridor 2 of 4 3 of 4 4 of 4 2 of 4 Average distance bed to en-suites 5300mm 5050mm 3950mm 5050mm Range of distance to en-suite sh/wc m m 2.5 x 5.5m m Full assistance in en-suite sh/wc Artwork Daylight factor (room average) ~2% ~2% <2% >2% Comparative cost factor savings 1.00 ~0.96 ~0.93 ~0.95 Completed projects using this arrangement Lilac Ward, Scarborough Hospital Diamond configuration Key features Head to head distance: at least 3600mm Full assistance in en-suite shower/wc Observation from corridor Average bed to en-suite distance no more than 5050mm En-suite access maintained when bed bay curtains closed Artwork Daylight factor (room average) c2% Several design features may be added to the designs, depending on local policy, including: Ceiling-mounted overhead hoists; Interstitial blind within the glazed screen; Furniture options; A medication cabinet; Patient entertainment system. The bedroom includes space for staff to work using a computer on wheels, but additional work space may be added. Clinical benefits 3600mm x 3100mm bed space reflects rigorous research by the Medical Architecture Research Unit at London South Bank University and the Health and Care Infrastructure Research and Innovation Centre at Loughborough University, indicating this space to be optimal in accommodating a full range of clinical i l activities iti taking place at the bedside or in the individual s bed space, together with operating equipment at the bedside; two clinical hand wash stations located in a highly visible and convenient area with a shelf above the basin on which staff may place papers, etc while washing their hands; good daylight with sightlines to outside space from the bedhead, providing a brighter, more therapeutic environment; family space, including the option of an overnight stay for a relative or friend; space for artwork within the room; Multi-Bed Bay includes an en-suite shower and WC and separate en-suite WC, providing patients with immediate access to a WC even if the en-suite is occupied. Bed locations are designed to avoid direct sightlines into the WC from the bed space; en-suite shower room is spacious enough to accommodate a bariatric patient. Diamond arrangement providing a balance of small bay footprint and corridor wall length, while increasing the bedhead-to-bedhead and bed-centreto-bed-centre distances plus observation of all beds from corridor and shortest distances to en-suites as well as space for artwork Bedroom NIA 58.5sqm En-suite NIA 6.3sqm En-suite WC NIA 1.9sqm Corridor r run 2500mm IPS 1.8sqm T-form arrangement providing the smallest bay footprint, a shallow plan depth and a window for each bed plus space for artwork, but longer corridor length Bedroom NIA 58.4sqm En-suite NIA 6.3sqm En-suite WC NIA 1.9sqm Corridor run 11150mm IPS 1.8sqm 6 For more details, please visit StandardShare on the ProCure21+ Club website For more details, please visit StandardShare on the ProCure21 + Club website