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BENNINGTON — A proposed $25.8 million project to nearly double the size and modernize the Emergency Department at Southwest Vermont Medical Center would be the first major upgrade for the ER since 1996, officials said.

According to a certificate of need application now under review by the Green Mountain Care Board, the upgrade is needed to accommodate a steep increase in the number of patients treated annually in the department since the mid-1990s — from 15,000 a year to an average of 23,700 in recent years.

The hospital "proposes to modernize its emergency department, hospital main entrance and entry area to address overcrowding, operational flow, and way finding on its campus," the application states.

The current emergency department provides excellent care, said Thomas Dee, president and CEO of Southwestern Vermont Health Care, "but the space was designed for 10,000 fewer people [annually].

In addition, he said, the need for more space for "behavioral care requires changes," making such a project "long overdue."

The hospital intends to renovate 7,700 square feet of building space and construct another 6,700 square feet to modernize the department, create a new main hospital entrance and relocate outpatient registration, phlebotomy and the imaging department's waiting room, as well as do minor upgrades to the laboratory and caf areas.

The expanded emergency department will have 18 treatment spaces, an increase of two, and the spaces will be enclosed rather than curtained off.

The project includes expansion of the mental health crisis care area to include five treatment spaces.

Southwestern Vermont Health Care Director of Planning James Trimarchi said in the application that the project "also includes extensive site work to improve traffic flow, parking, and wayfinding."

"SVMC has not significantly upgraded its hospital-based facilities in decades and has one of the oldest physical plants of Vermont hospitals," the application states. "This project would be the first major facility investment in more than twenty years and is critical to SVMC's future success."

The hospital hopes to receive CON approval from the state board before September, which would allow for a groundbreaking in early 2021 and completion of the project in 2023, according to the application.

Multiple issues cited

Among the issues the project would address, the application states, are treatment rooms that are undersized, limit space for the care team, and hamper effective use of technology, and rooms that don't meet contemporary building code standards.

Maintaining patient privacy also is challenging, the application states, since treatment rooms are separated by curtains.

Because of "the open treatment spaces, verbally loud and disruptive patients unsettle other patients seeking care. This is particularly problematic when treating persons in mental health crisis or struggling with substance use disorders," according to the application.

The facility also "segregates the care team, creating operational inefficiencies, and disrupting effective communication and care delivery. In addition, the spaces provided for the care teams are inadequately sized. Infection control is challenging given the open treatment spaces, thinly separated by curtains."

The application continues, "The emergency department has become the frontline of treatment for mental health concerns and substance use disorders. The current mental health crisis care spaces are insufficient and do not allow destigmatized, trauma-informed, person-centered care.

"SVMC's emergency department care team, led by board-certified emergency medicine physicians, delivers excellent care." the application states. "However, the current facility hampers the care team's ability to advance the Institute of Medicine's triple aims: to improve clinical outcomes and enhance the patient experience, advance the population's health by assessing and addressing socioeconomic underpinnings, and reduce the cost of care.

The rationale to modernize SVMC's emergency department, the application says, "extends beyond the significant reasons bulleted above and reflects a general need to `reboot' the emergency department care delivery model to: improve operational efficiency, reduce treatment times, enhance the patient experience, improve provider and care team collaboration, advance staff morale, and facilitate modern care delivery that improves patient outcomes."

Project details

Providing greater project detail, the application states that four vertical treatment spaces would be fitted with treatment chairs rather than stretchers to encourage rapid treatment and discharge to home for low-acuity patients (tick bites, urinary tract infections, etc.)."

In addition, two adjacent advanced trauma treatment spaces near the ambulance bay and helicopter pad would be created; a treatment space for airborne infectious isolation would be created, with a separate bathroom and negative airflow through an isolated rooftop exhaust."

In addition, "all treatment spaces would have three hard, sound-proof walls and retractable hand-wave activated doors to minimize infection transmission," and the project would "implement a single, centralized care team collaboration space to ensure effective and efficient communication to support timely diagnosis and treatment."

Six exam rooms would be in direct line-of-sight from the care team collaboration space, including five treatment spaces for high-acuity medical patients. Telemedicine equipment would be installed in most treatment rooms to virtually connect to specialists for consultation in diagnosis and treatment.

Mental health rooms

Mental health crisis treatment rooms would expand from three to five, and include "a group room for visits with family, peers and support persons," as well as "provide flexibility to secure parts, or the entire care area, based on the attending provider's assessment and best-practice related to the patient(s) status."

The proposed new department would also allow "separation of high- and low-acuity individuals or the flexibility to separate pediatric and adult individuals to enhance safety."

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It would also "maintain freedom to leave. The unit will be unlocked such that persons voluntarily seeking mental health care may leave. The limited number of higher acuity persons with evaluation status will receive person-center care in the secure area, while efforts advance towards placement at an acute mental health facility."

Those rooms would also have "windows providing natural light into each individual's room, including those in the secured area; offer entry to the mental health crisis care area directly through triage and the ambulance bay, allowing discrete access for individuals that need care. Family and peer supports will enter without exposure to the medical care areas of the emergency department."

The project would allow expansion of current tele-psychiatry capability throughout the mental health crisis care area, including the group room for guided group and peer support counselling," and "build a care team collaboration space that ensures effective team-based, trauma-informed care in the mental health crisis care area."

Nearly 25 percent of the modernized emergency department will be dedicated to the mental health crisis care area, the application states, adding, "To facilitate layout that facilitates best-practice care, the mental health crisis care area was purposefully designed into the new construction section. The mental health crisis care area comprises nearly 50 percent of the new construction."

The mental health crisis care area was designed to ensure destigmatized, trauma-informed, patient-centered care for a vulnerable population, the application states.

The project also would provide "adequate storage that is adaptable to the ever-changing supply and medical device needs of emergency care; improve safety of patients and staff by establishing best-practice access routes, salliports, and a security station within the emergency department."

New main entrance

The new construction would extend into the current main traffic route to the emergency department and hospital main entrance, requiring re-routing traffic traffic flow and construction of a new main entrance and lobby.

Creating a new hospital main entrance provides an opportunity to solve another long-standing patient issue, according to the application: wayfinding to registration for outpatient care.

"More than 75 percent of the care delivered by SVMC is outpatient care, yet the registration area is currently tucked down hallways and around corners," the application states. "This project will relocate outpatient registration to a prominent and convenient location within the new lobby. Repositioning outpatient registration will include relocation of the associated phlebotomy area and the imaging department's waiting area to improve operational efficiency and enhance the patient experience."

The hospital caf in the lobby will receive cosmetic improvements and seating enhancements.

Rerouting vehicle traffic flow to the emergency department and new main entrance "will be facilitated by removing an aged structure, the Lodge Building, which currently blocks sensible traffic flow, convenient parking close to the hospital's main entrance, and visual wayfinding," according to the application.

The hospital's finance team currently works in the Lodge Building and will be relocated. The cost of renovation of the new space for the finance team is included in the project cost, as well as the cost of demolition of the Lodge Building — located across the drive from the current main entrance.

Modernizing the emergency department is proposed to occur in phases to allow continuous safe treatment of patients. The first phase will include removal of impinging outbuildings; upgrading critical mechanical, electrical, and plumbing infrastructure; and creating temporary access to the hospital main entrance.

The second phase would involve the addition to the emergency department. The third and fourth phases would involve renovations of sections of the existing emergency department by temporarily relocating services to the new addition.

At no time will the emergency department have fewer than 16 patient treatment spaces.

Financial impacts

The financial package for the project includes $6.9 million in equity from funds the SVHC Foundation has in hand, left over from a hospital project from the early 2000s that did not come to fruition; expected or pledged fundraising contributions of $14.5 million and net debt financing of approximately $4.3 million, the application states.

According to the application, the foundation, through its Vision 2020 fundraising activities, is anticipating more than $14.5 million to be raised for the project.

SVHC's Foundation has received approximately $2.7 million in cash, with the remaining nearly $12 million as secured unconditional pledges of $2.6 million, secured conditional pledge of $5 million; and $4.5 million in future pledges to be received.

Included in the financial plan is a $10 million loan, to be executed about halfway through the project with $5 million to be repaid when the project is complete and the conditional pledge is received.

Project partners

SVMC's partners, Lavallee Brensinger Architects, of Manchester, N.H., and PC Construction, based in Burlington, have healthcare experience and have validated project cost estimates against benchmarks, the application states.

"During schematic design, Lavallee Brensiger Architects explored many design configurations and ultimately settled on a layout that meets the functional programming needs consistent with efficient constructability. This balance delivers the project in a most cost effective manner."

PC Construction "has extensive experience completing projects on time and under budget. PC Construction will employ local subcontractors thereby reducing unnecessary contractor travel expenses and insuring project spending enters the local economy."

Jim Therrien writes for New England Newspapers in Southern Vermont, including the Bennington Banner, Brattleboro Reformer and Manchester Journal. Twitter: @BB_therrien


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