Construction Digest: Good as gold

At most hospitals, the “golden hour” describes those precious 60 minutes after a serious injury when emergency medical care can make the difference between life and death.

The evocative term takes on a very different connotation at Ireland Army Community Hospital. That’s because the half-century-old hospital is located in the middle of Fort Knox, the U.S. Army base in Kentucky that serves as home to the nation’s world-famous gold bullion depository. It must be somehow comforting for hospital employees to know that there is more than $6 billion worth of gold bars stored in a highly secure vault just down the road—even if they can’t get anywhere near the building, much less in it.

“To be honest, since nobody—and that means nobody—can get access to the depository, or even anywhere near it, it’s like working near a fable. You wonder if it really even exists,” says Steven Braverman, a U.S. Army colonel and physician who is commander of the hospital. “As one of four colonel-commanders on the post, I have no more access to that than you do. Of course, it gives you instant recognition outside the base—everybody’s heard of Fort Knox because of the gold … mostly from the James Bond movie ( ‘Goldfinger’).

“If you hit a golf ball anywhere near it, alarms go off,” Braverman jokes.

Ireland Army Community Hospital—built at the height of the Cold War for as many as 500 patients a day—is notable in other ways as well. Most hospitals and health systems are in the midst of a national building boom. More than $41 billion was spent in the U.S. last year on healthcare construction, a record figure, according to FMI Corp., a consulting firm. Hospitals across the country are adding capacity like crazy, building new patient towers with large private rooms that feature amenities such as high-speed Internet connections, room-service menus, wall-mounted plasma televisions and spacious bathrooms with high-end fixtures.

Not Ireland. In fact, many of the patient rooms in the nine-story hospital building do not even contain their own bathrooms, much less a high-end television.

And the hospital isn’t exactly growing by leaps and bounds. It has actually shrunk, undergoing a wholesale restructuring and renovation in recent years that includes a multimillion-dollar energy efficiency overhaul. All but the first three floors have been given over to administrative offices and small, outpatient clinics that focus on areas such as occupational health, preventive medicine and dermatology, says Braverman, whose specialty is physical medicine and rehabilitation. The hospital has 31 inpatient beds in a mix of single and double rooms, says hospital spokesman Jerry Merideth, although the American Hospital Association officially lists Ireland at 76 staffed beds. There also are 16 outpatient spaces for same-day surgery.

But big isn’t necessarily better, Braverman suggests. And Ireland’s well-targeted overhaul on a limited budget—it spent about $10 million on both its energy makeover and interior renovations in recent years—could serve as a useful lesson for other small healthcare facilities hoping to stretch dollars. Previously, the last major update to the hospital came about 33 years ago, when the main hospital tower was built.

“In our system, we compete for limited dollars for military construction,” Braverman says. “And funds for any kind of a significant facility are pretty much spoken for, so we are doing the best we can to take an old building and bring it up to standards so we can continue to operate and provide good care for our patients.”

On a typical day, Ireland’s medical and nursing staff will handle anywhere from 800 to 1,000 outpatient visits, while the inpatient side deals with an average of 14 to 16 patients, Braverman says. The Fort Knox medical department, a far-flung operation, includes Ireland and outlying clinics that serve tens of thousands of active-duty soldiers and their families at locations as far away as Illinois, Indiana, Michigan, Ohio and Wisconsin.

When Braverman took over as commander about two years ago, the aging facility in central Kentucky, just 35 miles south of Louisville, wasn’t exactly patient-friendly or easy on the eyes. He says the hallways looked like they hadn’t been updated for several decades.

“When I first walked into the hospital, I noticed a lot of the corridors had a 1970s—or 1960s—motif,” he says. “Brown tile floors, golden-orange walls. Harvest gold and avocado green were the colors of the day in the ’60s. It wasn’t inviting.”

While traditional community hospitals are erecting entirely new buildings with grand lobbies that resemble five-star hotels, facilities like Ireland usually must take an incremental approach to improvements. Thus, over the past two years or so, the corridors in high-traffic areas at Ireland all have been remodeled and updated, with fresh new tiles, ceilings, walls and light fixtures, at an average cost of about $250 per linear foot.

The budgets at hospitals like Ireland were further constrained because much of the funding for new military hospitals had already been committed to future facilities at Fort Belvoir, Va., and the new Walter Reed National Military Medical Center in Bethesda, Md., among other sites, Braverman says.

In 2005, top officials in the Pentagon had recommended closing inpatient services at Ireland, a proposal that was rejected in a 7-2 vote by the Defense Base Realignment and Closure Commission that same year. Since that reprieve, the hospital has taken on a new life despite cash constraints, and now serves the medical needs of about 33,000 men and women on active duty.

The hospital is located near the center of the base, which sprawls across 109,000 acres of rolling hills in four Kentucky counties. And it’s about two miles down the road from the U.S. Bullion Depository, which holds some 147.3 million ounces of gold—more than 4,500 tons—within its impenetrable steel and concrete walls. Each gold bar, about the size of a standard building brick, weighs in at around 400 ounces, or

27.5 pounds, a bauble worth about $16,888 based on the statutory gold price of $42.22 per troy ounce, or a total of $6.2 billion. On the open market, however, where gold was selling for about $635 per ounce early last week, that stash would be worth about $93.5 billion.

Ireland is one small part of a vast health system run by the U.S. military through its Tricare program, the uniformed-services version of Blue Cross and Blue Shield. The system includes 70 military hospitals, 411 medical clinics and 417 dental clinics. It’s run by more than 88,400 military personnel supplemented by approximately 44,000 civilians, and serves about 9.2 million eligible beneficiaries. In fiscal 2006, Tricare spent more than $37 billion.

How busy is the military healthcare system? Each week, Tricare handles approximately 18,300 inpatient admissions, 1.8 million outpatient visits, 2,200 births, 2.1 million prescriptions and 104,000 dental visits. The total weekly tab: about $711 million.

The Ireland hospital, which was built in 1957, has undergone a complete overhaul of its heating, ventilation and air-conditioning system in recent years. (When it opened, it lacked a cooling system.) The project, coordinated by Trane, a large national company that provides energy-efficient HVAC systems, includes an automated program that controls climate, lighting and energy use throughout the hospital. As part of both an environmental and aesthetic makeover, reflective window film was installed throughout the building.

With the replacement of the entire heating and air-conditioning systems, the project cost about $8.8 million but is expected to provide energy savings of $1.4 million each year, the contractor says. The improvements at Ireland were a key part of a larger energy-efficiency project throughout Fort Knox and the military medical command, says Lt. Col. Guy Kiyokawa, assistant chief of staff for Installations, Environment and Facilities Management at the U.S. Army Medical Command in Fort Sam Houston, San Antonio.

One of the Army’s key initiatives, he notes, is to achieve better energy efficiency in new building and renovations, especially considering that many of the refurbishing projects involve older buildings. “When we do renovations, we ensure that specifications highlight the types of equipment and systems that are most energy-efficient,” he says.

The hospital’s focus on energy efficiency is part of a fast-developing trend in the healthcare industry, according to Gail Vittori, co-director of the Center for Maximum Potential Building Systems, a not-for-profit organization in Austin, Texas, that promotes environmentally friendly construction. The industry still lags behind many business sectors, but there are indications that it is moving “quickly and forcefully” into more environmentally conscious construction, Vittori says. For now, only eight hospitals have achieved a certification known as Leadership in Energy and Environmental Design, or LEED, a designation sponsored by the U.S. Green Building Council. But about 100 hospital projects are now registered for LEED and seeking that designation through the council, which is a coalition of leaders from across the building industry. “The movement is absolutely picking up speed in healthcare,” Vittori says.

Brandon Marcum, a spokesman for Harshaw Trane, an independent Trane franchise based in Louisville, Ky., says the new energy systems at Ireland would likely qualify the hospital for LEED certification for existing buildings. But the project was completed before the buildings council developed a ratings system for existing structures.

While Ireland’s energy systems were completely overhauled, several other sections of the hospital were updated as well. The Army hospital also spent about $1.3 million for renovations that included expanding primary-care facilities; the hospital opened its new Women’s Health Center in early December on the third floor of the building.

That change was made in large part to accommodate a significantly different population of patients at Ireland over the next several years, Braverman says. Fort Knox has long served as a primary site for the Army’s Armor Center and School, which includes about 4,000 military and civilian employees. That center is being transferred to Fort Benning, Ga., while Fort Knox will inherit a new infantry brigade as well as the Army’s Human Resources Command, among other additions, officials say. Overall, almost 4,800 permanent personnel will be added to the base, including many more families, women of child-bearing age, civilians and retirees.

Braverman anticipates as much as a 30% increase in business at the hospital in the near future, much of it in the newly renovated women’s center. So the relatively small amount of money that went into renovating the third floor will definitely provide a return on investment, he says. The improvements, he notes, meet two of his principal goals.

“In terms of my command philosophy, I want to generate improvements in how we are able to provide quality care for our patients,” Braverman says. “One of my other goals was changing—and improving—facilities to make patients more comfortable.”

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