Guiding Light, (c) Amy Eagle, Health Facilities Management, 12/06

Privacy and natural light are two hallmarks of modern health care architecture, making the design of Sheppard Pratt Hospital, which opened in 1891, more than 100 years ahead of its time.

The Towson, Md., psychiatric institution, originally known as the Sheppard Asylum, was founded by prominent 19th century businessman and philanthropist Moses Sheppard. Sheppard’s charter for the hospital foretells much of the current thinking on patient-centered healing environments; it calls for patients to be treated in a comfortable setting with privacy, sunlight and fresh air.

Sheppard was influenced by the work of mental health advocate Dorothea Dix, as well as his own Quaker faith and his experience as Baltimore’s prison commissioner, in which he witnessed firsthand the inhumane treatment of people with mental illness.

The original hospital campus and buildings were designed by Calvert Vaux and Frederic Law Olmsted, whose other notable collaborations include New York City’s Central Park. Despite periodic updates, the hospital’s historic buildings had become seriously outdated.

Dr. Steven S. Sharfstein is president and CEO of the not-for-profit Sheppard Pratt Health System, which is based in Baltimore and operates mental health facilities throughout Maryland. He says that by the mid-1980s it became apparent that the Towson hospital, while classic and beautiful, had to be “radically redesigned or rebuilt” if it was to provide modern health care requirements.

Or both, as it happens. A significant renovation of the original hospital building is scheduled for completion later this month. A new building, named for philanthropists Harry and Jeanette Weinberg, opened in March 2005. The Weinberg Building adjoins the existing facility via an enclosed pedestrian corridor and, at 234,000 square feet, it nearly doubles the size of the existing hospital.

HDR Architecture, based in Omaha, Neb., with offices in Baltimore, is the new building’s architect of record. Robert A.M. Stern Architects, New York City, served as the design architect. The project was managed by the Baltimore office of Atlanta-based Heery International. The Whiting-Turner Contracting Company, headquartered in Baltimore, was the general contractor.

Four major goals

Rick Abbott, AIA, principal-in-charge on the project for HDR, says the design and construction team had four major goals for the facility: to blend the new structure with the original hospital building, to improve on the existing hospital’s inefficient corridor system, to create the first psychiatric hospital in the nation with all-private patient rooms and bathrooms, and to position the hospital for its next 100 years of growth.

The original hospital building is on the National Register of Historic Places; however, the site also included several structures that were not listed as such. The architects chose to remove some of these, but retained the hospital’s old power plant. This building was redesigned to house the new facility’s infrastructure support system on its lower levels, with medical offices on the upper floors.

Since the builders were not able to take geotechnical borings where the existing structures were located, they unearthed a few surprises during excavation, including some large cisterns and a great deal of intractable rock. The rock, mostly granite, required blasting to be removed. This was a delicate operation, considering the proximity of the historic buildings.

“The old power plant was on a dry stack foundation, and we were blasting to within 20 feet of it,” says Scott Martin, CCM, project manager for Heery International. “Fortunately,” he adds, laughing, “Whiting-Turner’s construction offices were in the power plant, so it was very much in their interest to make sure it didn’t fall down.”

In the most sensitive areas of the site, the rock was perforated with a 6-inch drill bit, then broken apart by jackhammer. “It was a very expensive, long and difficult process to take out all that rock,” Martin says. But the builders were able to adjust the construction schedule so that removing the rock cost them only 60 days overall.

Comfort and privacy

In designing the new facility, the architects strove to continue Sheppard Pratt’s legacy of architectural excellence and compassionate care. The stone and brick exterior, slate roof, copper gutters and fascia complement the original building, while the interior provides the comfort, privacy and security the hospital’s founders advocated.

Sharfstein notes that in the past 15 years, with the advent of new psychopharmacological treatments, psychiatric care has become more short-term and medical in nature. Because drugs help many patients manage the symptoms that can put them in the hospital, such as hallucinations or delusions, much of psychiatric care now takes place in the outpatient arena, he says. He adds that for this reason, the Sheppard Pratt leadership felt that hospital care, which is reserved for the most desperate patients, should be “very good care in a very attractive environment.” They wanted to create a setting that was welcoming, not frightening, and maximized patient privacy.

These were the key factors in the design of the new building’s corridor system. In the old hospital, newly admitted patients, often in restraints and a great deal of distress, had to be taken through public areas and other units and, perhaps, even past housekeeping or dietary carts on their way to a room.

“With the new circulation, we have been able to separate all that,” says Abbott. A dedicated patient transport elevator provides a more dignified and pleasant arrival process for patients and their families. Separate corridors also enable the hospital staff to work much more efficiently.

Similar thought went into the inclusion of private patient rooms in the new building. “Private rooms are really the state-of-the-art in psychiatry, as in much of medicine,” says Sharfstein. Although private rooms are not yet common in psychiatric care, they have become standard in other areas of health care design. But psychiatric patients benefit from increased privacy and the absence of roommate conflicts just as much as anyone, according to Sharfstein.

Additionally, with private rooms, the hospital can increase patient volume because admissions are no longer limited by the availability of only a male or female bed at any given time.

Protecting patients

Safety was paramount in the design of the patient rooms. Abbott says, “The driving force in psychiatric design is to protect the patients from themselves, and also to protect the staff.” Every detail of the rooms was analyzed for potential harm.

For example, the ceilings in the patient rooms are 10 feet high to prevent patients from being able to reach light fixtures or fire sprinklers. Solid plaster drywall ceilings were installed instead of drop ceilings to restrict access to the area above the ceiling.

Throughout the hospital, the patient areas have tamper-resistant, hospital-grade electrical outlets attached with tamper-proof screws. Ground fault interrupt (GFI) breakers in the outlets prevent patients from using them to start fires. Each patient room is circuited separately so that hospital staff can turn off the outlets in any particular room if a patient is noncompliant.

Edges and corners in patient areas are rounded off. Door hinges are sloped on top and ceramic tiles are curved at the edge. The window manufacturer modified the design of the window frames used in the patient rooms by filing down a sharp edge on each frame.

The exterior windows in all patient areas are composed of glass-clad polycarbonate. “This gives you the impact resistance of polycarbonate, with the maintenance properties and durability of glass,” says Martin. Sandwiching the polycarbonate between layers of glass prevents the scratching and clouding that can occur with directly exposed polycarbonate, he explains. Interior windows are made of tempered laminated glass, the same material used for automobile windshields.

The bathroom mirrors were originally to be polished stainless steel, but the patient room mock-ups revealed this material to have poor optical qualities. Tempered glass with a metal backing plate was substituted, then replaced with more durable polycarbonate.

The bathroom fixtures are prison grade and very durable. The showers are controlled by a push button that dispenses water for approximately three minutes at a predetermined temperature. This way, patients cannot burn themselves or block the drain and flood the room. Shower curtains are hung with Velcro fasteners.

A shroud covers the plumbing under the sink, to prevent burns. The shroud is enclosed so that contraband items cannot be hidden in it.

Color is used to create warmth in the rooms, which are otherwise fairly sparse. “The patient’s room is really intended just for sleeping,” says Abbott. “Once patients wake up in the morning, the intent is to get them out into social functions, so they’re interacting with society.”

The separate corridor system allows the hospital staff to escort patients to other parts of the building in a controlled environment.

Visibility on the patient floors is another safety feature. “The new hospital has superb visual lines,” says Sharfstein. Central nurses’ stations enable staff members to view potential problems before they become dangerous.

Furniture was selected for its strength, as well as its attractiveness. “It takes a lot of abuse. Fortunately, health care furniture has come a long way in the past decade,” says Abbott. While sturdy, institutional furniture of 10 years ago often looked “like it was built of packing crates,” he says, newer lines combine durability with the aesthetics of a homelike environment.

Throughout the project, the architects and designers worked to strike a balance between aesthetics and safety. “That was a constant issue, and whenever we came to a decision we tried to consider both,” says Martin.

For example, the hospital’s extensive art collection is carefully displayed in such a way that people can enjoy the art but cannot damage it or use it to injure themselves or others. “The framing methods and protection methods on the artwork are equally impressive as the artwork itself,” says Abbott. “It’s quite inventive.”

The designers also endeavored to respect the hospital’s Quaker heritage, choosing simple lines and muted colors that not only honor the institution’s history but are soothing and well-suited to the psychiatric environment.

Into the future

The building is also designed to continue the legacy far into the future, whatever that future may bring.

“We wanted to make sure that whatever we did inside, it could easily be adapted to other purposes,” Abbott says. Although psychiatric care does not require the clearances for stretchers and wheelchairs that are necessary for acute medical care, the building was designed with 8-foot corridors and handicapped-accessibility features that will enable it to be converted to a nursing home or acute care medical hospital if needed.

The building also has few fixed internal structural elements, so that the interior can be rearranged as necessary. “We tried to look in the crystal ball as far out as possible, so that as new methods of delivering psychiatric care are adopted, this building could adapt itself to create the environment for those modes of operation,” says Abbott.

The design also allows for short-term flexibility. The patient floors are standardized to enable the hospital to respond to changing patient populations without rebuilding or remodeling customized units. For example, if the adult patient census rises and the child census lowers, adults can simply be moved into a former children’s unit.

“One of the units actually changed functions before the building even opened, so that proved to be a valuable approach,” says Martin.

Cutoff doors in the corridors between nurses’ stations make it possible to alter the size of the nursing units almost instantaneously. By deadbolting one of three pairs of doors that are located along the corridor, hospital staff can change which patient rooms are assigned to which nurses’ station. This allows staff to adjust their census per diagnosis quickly.

‘Outstanding’

The Weinberg Building manifests the institution’s founding philosophy. “The founders said, ‘Do everything for the comfort of the patient,’” says Sharfstein.

“It’s not a happy experience to be hospitalized for any reason, and certainly not for psychiatric reasons, but the reaction from patients and families has been outstanding. And the staff loves it, too.”