By: Gil May
Most of us — architects, contractors and owners, alike — prefer the opportunity to work on a shiny new healthcare building that allows us to design, build and operate free of restrictions imposed by existing conditions. However, the reality is a great deal of healthcare design and construction involves the renovation of existing buildings, spaces and infrastructure. Healthcare systems constantly face the need to adapt, enlarge and upgrade existing facilities to address new and/or expanded programs, support improved patient care models or simply to accommodate the best and latest equipment.
Rarely, if ever, are these improvements nicely isolated in a corner of the building, with independent MEP systems and with nothing to disturb above or below it. Instead, the expression ‘we’re changing the tire on the car as we’re driving down the road’ comes to mind. The renovations must occur while still serving patients in directly adjacent areas.
If the project is an outpatient building, much of the work can occur overnight. In an inpatient setting, daytime construction can disrupt the busiest hours when the building is most in use, while nighttime construction risks disturbing patients’ much needed rest. Either way, careful consideration, meticulous planning and a steadfast focus on patient safety are essential — especially during phased construction, where risks and complexities multiply.
Phased construction introduces unique challenges, making infection control a critical focus from start to finish. The key lies in a seamless collaboration between the owner, architect and contractor — ensuring every decision supports patient safety and uninterrupted care.
Impact on phasing and infection control
This collaboration begins with understanding how the project must be phased. When renovating existing healthcare spaces, more often than not phasing is driven by operational needs instead of construction sequencing requirements.
For instance, space A must be completed first for the end-users from space B to move into, then space B can be renovated for its new purpose and so on (the domino effect). We also frequently run into scenarios where, because of stressed resources and high volumes, only X number of rooms can be taken off-line at a time.
In both cases, the operational necessity for phasing requires an adaptable and variable infection control approach. Not only must each phase be considered independently and have its own tailored infection control approach, it’s important for the team to discuss what happens in the transition between phases. When does an existing barrier come down and how are patients protected during its deconstruction?
As a result, it’s essential for the design and construction teams to work with the owner to find the right balance between the number of phases that maximize operational continuity, while also minimizing the opportunities for infection control risks created by complex sequencing.
Infection control interdependencies between phases
Once the operational requirements for phases have been hashed out, next the team needs to understand the impacts of the phasing on the existing systems. Special attention is required for the HVAC system to reduce the potential of airborne infection risks.
Often an existing air handling unit will serve a larger area across multiple phases of the project. The design and construction must accommodate partitioning off portions of that system for the phase under construction to prevent cross contamination from construction dust, etc.
According to Greg Johnson, P.E., LEED AP, and partner at the MEP firm Newcomb & Boyd, “Before construction and ideally really even before design, review of a recent or new test & balance report and the existing conditions is necessary to understand what modifications are needed. This includes not only alterations to the supply and return ductwork, but also the air handling unit and exhaust systems serving the space. It is possible that the balance of the air handling, especially the return air and outside air, must be adjusted, and sometimes adjusted multiples times to coordinate with the phasing requirements.”
The design needs to account for supply and return ductwork to be disconnected and sealed off outside the construction area for as long as possible during each phase. The locations of connections to active mains should be selected to facilitate ease of infection control barriers — these must also be made during a system shutdown to avoid introducing contaminates into the system. Filtration is required in return systems. Where plenum return is utilized, the construction barriers for each phase must go to, and be sealed to, the deck above.
Construction & activation
During the design phase and prior to the start of construction in an occupied building, a risk assessment must be performed. The assessment must take into account the impacted patient population in the project area and the adjacent departments (beside, above and below). While thorough attention is required in all healthcare projects, the strictest infection control measures must be used for any areas where patients are immunocompromised, such as inpatient or outpatient oncology spaces. For phased projects, an assessment must be considered for each individual phase.
“After we develop a plan, we always have a meeting with the end user, IP and anyone that needs to approve our plan. It is critical to get buy-in and have all the protocols documented and agreed to. Collaboration of all stakeholders’ expectations at each construction phase is critical,” advises Mike Schilling, chief operating officer for healthcare contractor Structor Group.
During construction, the contractor must also carefully plan for access routes to and from each area to avoid cross contamination in areas that are to remain operational during that phase. This may mean temporarily taking over a particular elevator or partitioning off a portion of a corridor that is not immediately part of the construction zone to allow for controlled access into the construction area (while maintaining proper interim life safety measures).
The area of each phase must be monitored to be under negative air pressure during construction. Temporary ante rooms into the construction zone are an essential part of this strategy. Automatic sensors and recorders are recommended. The negative air equipment itself is also an important part of the plan. It should include a HEPA filter, so discharge air is clean. Where it discharges is also critical; when possible, directly to the exterior is ideal.
It is also worth noting that infection control does not stop with the contractor’s construction work. The completion of each construction phase is like a mini-activation project. Similar infection control consideration must be given to move planning, equipment and furniture delivery and IS and AV installation, particularly access routes.
Communication
Lastly, during a phased construction project, communication with the end users is paramount. Inherently, a phased project is fluid and changing throughout construction. Sometimes phases last months long, but often they are just days or weeks. As discussed, the infection control approach also may change between phases based on the nature of the work, the patient population impacted, access or simply lessons learned from the previous phase.
“A successful construction infection control strategy involves our end users. They need to be well-informed and kept up-to-date about the phases, changes and how those changes may impact their daily operations,” notes Abigail Stroud, director of facility planning, design, and construction of Emory Healthcare’s Physician Division.
Phased construction raises the stakes, requiring every decision to balance progress with patient safety. In an operational building, infection control shifts from a static checklist to a proactive mindset — demanding anticipation, adaptability and an unwavering commitment to safety. True success is measured not just by the work completed, but by the care maintained every step of the way.
Gill May, AIA, IIDA, LEED AP, is founding principal of May Architecture.
