Bed count

Elizabeth Broomhall , July 18th, 2010

As the demand for hospital beds increases across the GCC, the number of construction projects in this sector continues to rise. But for those looking to bid in this developing market, hospital building presents a number of challenges. CW investigates the issues and complexities involved in construction.

Financial crisis or not, hospital projects are one of the few types of development that are unlikely to slow down.

Leading the GCC with a US $10 billion hospital building initiative currently, Saudi Arabia is certainly preparing for a sharp rise in hospital demand, whilst according to healthcare engineering experts, Kuwait has set aside roughly KD37 billion (US $127 billion) to spend on hospital projects in the next four years with a view to replacing inadequate facilities built three decades ago.

In the UAE, two of Abu Dhabi’s biggest projects include the complete refurbishment of both Al Ain and Al Mafraq hospitals, whilst in Dubai, a report by the Chamber of Commerce and Industry anticipates as many as 17 new hospitals providing 2,325 beds will be built in 2010 alone.

The increase in demand, expected to hit a massive 165,000 beds by 2025, pushing healthcare costs up five fold to US$60 billion according to a report by McKinsey, is partly due to a growing prevalence of Type 2 diabetes and obesity throughout the region, as well as increasing populations and a fresh influx of expatriates.

In some countries, there is an additional necessity to bring in more healthcare tourism.

But with a growing need for healthcare facilities, inevitably, there emerges a new demand for hospital building, and as with all developing markets, it is critical for contractors, architects and consultants to consider the pros and cons.

Speaking about the negatives, WSP Middle East’s technical director for healthcare Carl Platt says: “Healthcare facilities are far more complex in their design than other types of projects. The entire construction team is liable for ensuring quality standards are met, and there are far more opportunities to get it wrong if you don’t know what you’re doing.”

On the other hand, he adds, there are plenty of new business opportunities for contractors and consultants, with a guaranteed demand for additional projects irrespective of the world’s economic challenges.

According to a chief designer of hospital projects from an Abu Dhabi consultancy, there may also be less competition for hospital projects due to their complex nature, while profit margins tend to be slightly higher and a good reputation awaits the relevant contractors.

But before firms can even think about the general risks of hospital building, industry specialists urge them to consider the less obvious complexities that make hospital construction so unique.

Big demands and tight specifications
“Hospital projects are more technologically advanced than standard construction projects as they have more intelligent systems built into them,” says Aldar Properties’ senior development manager Hadi Sha.

“Due to the number and complexity of these systems, there is typically a lot of infrastructure congestion which can create coordination issues and slow construction down. Medical equipment, IT and security systems for example are constantly being updated during the construction period, which can mean last minute modifications are required.”

At the same time, he maintains, contractors and designers are expected to ensure a certain standard of quality.

“Minimising the changes to the project can help prevent a number of issues, but it is part of the industry’s DNA to continuously seek new and innovative methods of delivering healthcare facilities without compromising on quality.”

Intensifying difficulties is the fact that the UAE has no specified healthcare standards, but tends to adopt US policies and Health Technical Memorandums (HTMs) from the UK when required.

Meanwhile, the projects continue to be subject to government and local health authority requirements, (which vary according to the individual project and regional demand), as well as an array of conflicting departmental specifications.

“Each hospital department has a different set of end user requirements,” says Meinhardt’s hospital expert and head of MEP division Stephen Clough.

“In some projects you can deal with as many as twenty different departments, so coordinating needs can be challenging. Often they each wish to impart their own set of requirements which may be contrary to the agreed general standards.”

Referring to a trend of tight programmes and detailed design specifications, he adds that collating comments and approvals from hospital operators can be a lengthy process.

“Budget can also be an issue as additional requirements by the end user can have a significant effect on costs.”

Whilst costs are generally not a huge concern for the more standard types of projects, when it comes to hospital building, the issue of finance continues to crop up. The Abu Dhabi designer says hospital projects are “definitely pricier than other projects,” and that the cost is often “two or three times the amount for a residential project per square metre.”

Platt agrees. “People don’t realise exactly how much it costs to build a hospital. Just because the projects are sometimes of higher value, doesn’t mean they necessarily yield more profits.”

Architectural sophistication
Whilst high rises, hotels and residential developments are commonly renowned for their architectural significance, it is actually healthcare facilities that invite the most advanced architectural thought.

One hospital feature that is particularly dependent on good design is the need for privacy, though the requirements will vary according to the type of hospital and location of the project.

In Saudi Arabia for instance, it is necessary to separate ladies’ and men’s sections when designing the unit, whilst the number of rooms and services of any facility may be affected by the unit’s medical specialty and average length of in-patients’ stay. The amount and size of equipment will also be considered.

As regards upholding patient dignity and care, space planning by architects is essential. “It can be difficult, but it is nonetheless critical to ensure adjacencies between departments for the sake of patient dignity,” says Platt.

“For example, diagnostic and imaging suites should be positioned close to accident and emergency departments.” Architects also need to take special care at the design stage, he says, to avoid patients being wheeled around highly populated areas on trolleys or in hospital clothing.

Designing the building in such as a way so as to eliminate the spread of noise through a facility may also be important, though Platt emphasises the role of engineers here, whose responsibilities include acoustic control through strategies like fitting attenuators in air ducts to limit sound travel.

Complex MEP works
Perhaps more widely acknowledged than the architectural complexities are the extremely specific MEP requirements of hospital projects – central to efficient operation due to the need for a closely-controlled, infection-free, safe environment, impervious to electrical failure.

The unique challenges, which largely revolve around thermal control, air management, power generation, waste disposal and equipment installation, not only impact on the MEP contractor, but on all parties involved in the project’s design and construction.

Unlike the UK where thermal control is about keeping hospitals warm, in the UAE there is a clear need to keep the facility cool. Contrary to standard projects where sustainable air conditioning systems are installed simply and easily, hospital cooling is more complex.

Burdened with having to balance the demand for cold air with that for natural light, hospitals are under pressure to reduce the amount of energy used by cooling systems whilst preventing the spread of airborne diseases – a difficult task given that most sustainable air conditioning systems rely on re-circulated air.

Platt explains: “One of the challenges of hospital building in the GCC is to reduce the large solar gains into the hospital. The use of glazing to provide natural light (proven to be beneficial in the healing process) can be problematic when you imagine what the inside of a car is like in the summer. But of course, we don’t want to simply install bigger chillers, due to the large amount of energy they consume.

“Thus, to maintain thermal control,” he goes on, “architects and engineers need to consider alternative options, such as greater insulation to keep warm air out, and shading options which can limit the solar gains onto the fabric of the building.

“The difficulty with re-circulated air,” he adds, “is that you risk spreading infection. In a normal building you would literally just re-circulate the air, but in a hospital, especially areas such as operating theatres and intensive care units, this is not possible, as you would be re-circulating contaminated air.”

A more efficient system, he explains, is to pump filtered fresh air into a room, pull the air out and just cool it down with the existing air. For architects, engineers and contractors, the means for doing this can be complicated.

Containing airborne diseases generally in areas of risk such as operating theatres and intensive care units is also complex due to the need to be positively pressurised to protect the patients.

“The mechanical systems in a hospital are very advanced, the MEP works specifically have a higher and tighter specification in a hospital than on other projects and there is more emphasis on air filtration,” says Clough.

“Services are designed in such a way as to compartmentalise areas to prevent the spread of airborne diseases, and the pressurisation arrangement has to be carefully considered.”

As it happens, infection is not only spread through the air, but through waste. Platt suggests waste disposal is also a huge consideration for designers and contractors, with different systems having to be installed for different types of waste.

“There are three types of waste in hospitals, one is the general waste from sinks and toilets, another is the chemical waste from laboratories and the last is the waste from cleaning and sterilisation.

Each type of waste must be managed separately so as not to enter the water system and spread infection. This creates additional challenges for construction firms and MEP specialists, who respectively have to design and implement these systems.”

When it comes to power, there are even more problems, since hospitals must ensure a continuous supply of energy at all times. According to Clough, they may even require many different back-up systems to provide electricity in the event of a mains failure.

“This is especially important in an operating theatre where a mains failure can be a matter of life and death,” he says.

Thus, hospitals need to have back-up generators and uninterruptible power supplies installed during construction, which Clough says must be “connected through one or more primary automatic transfer switches, to emergency lighting systems, alarm systems, blood banks, nurses’ calling systems, telephone equipment, task illumination and receptacles in patient-critical areas.”

Linked to this issue is that of equipment installation. Since each division of the hospital is likely to require high-tech equipment, installation jobs would be extremely difficult for non-specialists.

“If you consider X-ray equipment for example,” says the Abu Dhabi designer, “it requires a specific power supply, certain wirings and cables, specific connections to the Building Management System (BMS), its own flooring requirements or platforms and room temperature control. The walls will also need to be insulated effectively to protect them from X-rays.”

And where multi-million pound machines such as MRI scanners need to be integrated, there is an added risk of serious financial outlay should the contractors take it upon themselves to install this kind of equipment and accidentally damage it.

Even where specialists are brought in, project managers should remain aware of the risk of damage caused by leaving equipment in the heat for long periods.

Tricky finishing works
The finishing works, sometimes perceived to be ‘post-construction works’, are extremely important in hospital building. According to technical experts, the need for perfection puts a substantial amount of pressure on those not only carrying out the finishes, but on the other contractors as well.

“On completion, a hospital building has to be immaculately clean,” explains Clough. “This means that nothing other than the equipment required should be left in floor or ceiling voids, dust has to be kept to a minimum during all stages of the build and surfaces have to be sealed.”

Central to these requirements is hygiene and the ongoing use of the building after construction – it being imperative to consider the long-term operation of the facility during the design, supply and construction phases.

“The paints and all the finishes must be washable and must not allow bacterial growth,” says the Abu Dhabi designer.

“All the materials and equipment installed must be suitable for their purpose for a long time without the need for regular repair and maintenance. In a hospital, you can’t tolerate failures or shut-downs for repairs.”

He adds that the public areas where operators expect heavy pedestrian and light equipment movement, must be fitted with heavy duty flooring and paintwork to protect them from damage.

Across the board, experts agree that successful hospital building boils down to quick and early coordination. This, on top of expert knowledge of the specific requirements, and an approach to building which is advanced as the systems themselves.

Integrated architecture and engineering is therefore paramount, alongside recognition that the hospital environment is profoundly influenced by the building form and envelope.