Florida Hospital Waterman in Tavares, Fla., serves the growing Lake County region with a full continuum of health care services. Like many hospitals, leadership grapples with how to meet growing demand and has been pursuing renovations and expansions. To help alleviate emergency department demand, Florida Hospital Waterman turned to Gresham, Smith and Partners for a four-story addition that will expand the emergency department and patient tower, shell two floors for surgical and medical units, and renovate the existing emergency department.

At Florida Hospital Waterman, repurposing parking space adjacent to the existing emergency department was the best location to expand. But, for patient flow and efficient operations, it was the most challenging location to expand. Our client’s preference is to maintain separate ambulance and patient drop-offs. However, keeping emergency patients flowing smoothly during construction can be like solving a jigsaw puzzle. Construction in the midst of the existing ambulance and patient drop-offs traffic takes special planning and emphasis on details. Keeping the emergency room open 24/7 requires a phased approach with sometimes multiple temporary ambulance and patient drop-offs, each with their own temporary canopies and access points. Temporary wayfinding signage is critical to minimize patient confusion, especially in stressful emergency situations.

The chosen site at Florida Hospital Waterman also presents grading issues because the existing parking area is at a higher elevation than the existing ground floor elevation. The addition’s floor elevation needs to match the existing emergency department for aesthetics and accessibility. But matching the floors has significant implications for directing stormwater away from the building. Complicating the design is a basement-level cafeteria that requires stormwater pumping. Appropriate grading is critical to accommodating stormwater run-on during heavy Florida rainfall to avoid any catastrophic water backups into the facility.

Like most building expansions and renovations, staying in business while undergoing construction is a “business-as-usual” challenge from a site planning and civil engineering perspective. But unlike some other uses, keeping a hospital emergency department operational is literally a life and death critical requirement. While space, patient flow, and grading present opportunities, the greatest challenge is phasing the relocation of existing utilities. This adds significant time and cost to an addition project. However, the difficulty is multiplied when working on a hospital. Unlike other buildings where there is “down time,” hospitals are open 24/7 and require access to utilities at all times.

At Florida Hospital Waterman, the Emergency Department expansion site impacts every primary utility, and all of them must be relocated — fiber optic, communications, natural gas, domestic water, fire water, public sewer, storm drainage, and electrical service to site lights and the building itself.

Following are some best practices for navigating this complex challenge:

Mind timing and maintain lines of communication — Phasing is always challenging when expanding an active facility. To set the project up for the best chance of success it is imperative to address all permits at the same time to avoid delays later. There should be a strong plan in place for utilities, including how and when to move them.

The number of stakeholders involved in moving utilities can make it very difficult. Utility companies each have their own inspectors and permitting processes. Coordinating these various entities and ensuring the right permitting at the outset can help mitigate potential issues. Communication with building engineers — mechanical, plumbing, electrical, and fire protection — is also key. Additionally, having the contractor at the design table early in the process is invaluable.

Do the (literal) groundwork — A thorough topographic map is extremely important. Vacuum excavation gives the most accurate location of the utilities, both vertical and horizontal. However, it is difficult to identify the utilities without clues on the surface. As engineers know, reliance on previous site designs can likely lead to underground surprises, usually during the first week of site construction. We continue to request our surveyors apply technology such as ground penetrating radar, which can provide more clues to hidden underground utility lines.

Think in three dimensions — Civil engineers work in a design world that includes what cannot be seen (underground). Therefore, it’s crucial to think three dimensionally about the vertical and horizontal directions and depth at which utilities run. Sewer and stormwater are both generally designed using gravity flow, which requires the slope of the pipe to be always flowing downhill. If there is conflict with another utility line, these gravity lines take precedence.

In the Florida Hospital Waterman Emergency Department addition project, the site is between the existing emergency department and a public road with stormwater draining toward the hospital. The stormwater solution had to take this and the basement level of the hospital into account while weaving the utilities through the design.

Expect surprises and be flexible — Even working with a good underground utility and topographic survey, surprises will arise. There are generally always discrepancies between the old site plans and the current location of utilities. When building addition construction starts, uncovering additional utility lines is the norm rather than the exception. Contractor coordination with the design team for a quick, nimble response will help minimize expensive construction delays.

Additionally, sometimes the best solutions do not always seem the most efficient. Projects must adapt, and in some cases that means building a temporary, throw-away connection — or even more than one temporary connection — before building the final connection. This is particularly relevant in hospital sites when construction must be completed with customers essentially in the middle of the work.

Keep Good Records

Documentation is part of being good stewards for clients and for anyone working in the area in the future, whether it be you or another engineer. Keeping meticulous records of where the utilities are finally constructed makes it much easier during the next project.

Expansions and renovations are effective ways to meet growing demand, but can present significant site planning challenges. One of the biggest challenges can be moving utilities, particularly in 24/7 sites such as hospitals where lives are dependent on uninterrupted access to utilities. Smart design and phasing, flexibility, and good communication can help minimize delays and cost overruns.   

Michael D. Hunkler, P.E., LEED AP, ENV SP, serves as a principal-in-charge for Gresham, Smith and Partners Land Planning & Design division. He is responsible for site design for the firm in the areas of health care, residential, retail, commercial, industrial, and recreation. He also has extensive experience in coordinating with and obtaining approvals from review agencies and planning departments across the country.