When the leadership team at Shannon Medical Center in San Angelo, Texas, first considered an expansion back in 2012, the scope called for a three-level addition. Those plans were scrapped, but in 2016 the team revived the project—this time with a 75,000-sq-ft, seven-story bed tower and more than 22,000 sq ft of renovations to four floors of the hospital. That included a full intensive care unit expansion and renovation, an expanded emergency department, more operating rooms and additional gastrointestinal procedure rooms and catheterization labs.

“We spent most of 2016 in design and then securing a contractor,” says Dale Droll, director of engineering at Shannon Medical Center.

The 26-phase schedule began immediately—even before contractor Hoar Construction was selected for the 32-month, $55-million project.

“We’re affecting highly intense areas of the hospital. Emergency department, surgery, those kinds of things,” says Matt Fabre, senior associate and health care practice leader at O’Connell Robertson, the project manager and lead architect on the project. “So we really had to think long and hard about, operationally, how the phasing was going to work.”

He acknowledges the disruptive potential of increasing the square footage of the building by nearly 20% while renovating about 20% of the existing building. “If you were building this amount of square footage free-standing, you could probably do it in half the time,” Fabre says. “But the amount of care that had to come into play with factoring in those operational considerations has dragged the schedule out, but necessarily so.”

Construction on the CM at-risk project began in January 2017. The delivery “was unusual for the client. I believe this is the second project they had used CM at-risk on,” says Sean Cagle, project manager with Hoar Construction. “The reason they chose that is they realized based on the complexity of the project, they needed to do something different to attract people to look at the project in the right way.”

Challenges on the three-year project included coordinating construction activity in close proximity to an active helipad and ensuring hospital operations continued unimpeded.

Site Logistics

Shannon Medical Center’s new tower addition is located just 75 ft from the hospital’s AirMed1, an active helipad that conducts about 786 missions per year across 13 counties.

On top of that, the team realized there was really no space for a laydown yard, given the tight sitelines on a street corner. The just-in-time deliveries were further complicated by debris and wind from the nearby helipad.

“Tower cranes would have gone into weather-vane mode sitting over the top of the helipad,” explains Jeff Light, director of division operations at Hoar’s Austin office. “So initially we looked at trying to use a mobile crane that could essentially simulate a tower crane called a luffing jib, a crawler crane. At the end of the day we ended up not having enough room to really erect that kind of crane without taking down some public utilities in the street.”

Instead, the steel erector, Deem Structural Services from Longview, Texas, came up with a plan to erect the building in a specific sequence, then backing out using a conventional crawler crane.

“It wasn’t the ideal situation, but we figured out how to get through it,” Light says.

To ensure limited disruptions, the team implemented a straight-line communication program with Shannon’s team, which controls departure and arrival of all emergency medical services.

“We were able to get notification when they were departing or arriving, and we had a full-time monitor in that the area,” says Clayton Salmon, senior superintendent with Hoar. The plan ensured adequate clearance for incoming helicopters and ambulances.

Cath Lab Redesign

As part of the project, the contractor is building out three state-of-the-art catheterization labs. The existing cath labs will be converted into endoscopy procedure rooms.

In the initial design, the cath labs were to be located on the third floor since the floor heights in the addition were dictated by heights in the existing building and how it ties in with new tower. However, when the hospital decided it would be preferable to have the cath labs on the fourth floor, where the heart department is currently located, the project team had to figure out how to make the new ceiling height work.

“This created a challenge because the floor height there is 12 feet floor to floor, so you lose 2 feet of overhead space,” Cagle explains. “Then you start looking at the Philips imaging equipment and the stuff to actually do a catheterization procedure—there was one procedure that required clearance of 9 feet, 6 inches from floor to ceiling, and the reflected ceiling height in that cath lab was 9 feet.”

That required a quick redesign and new BIM modeling for the space, modifying the structure and MEP systems and pushing items such as diffusers, light fixtures and electrical conduits to the perimeter of the room. After that, the team raised the ceiling in the center of the room, where the imaging equipment and exam tables were located to create the 9-ft, 6-in. clearance.

“It caused a drastic redesign of those three rooms and the infrastructure feeding those rooms midway through steel erection in that tower,” Cagle says. “So that was about a six- to eight-week challenge going through and redesigning those spaces.”

The team used some of the steel that had already been fabricated and placed additional steel across the space.

“We were able to catch it soon enough and work through it quickly enough to where we were able to minimize the impacts from a cost and schedule perspective with the owner,” Cagle says.

Air Handlers and Concrete

Completing air handler upgrades proved to be another challenge, particularly the air handler that serves existing operating rooms. “Having to change that out completely takes those rooms offline during the process,” Salmon says.

The team planned the work within a 96-hour window during spring break, when crews swapped out the air handler, ductwork and controls. All the extensive planning and early work done ahead of the switch out enabled the team to complete the installation in 64 hours, allowing the space to be recertified 32 hours early.

Since the new tower connects directly to the existing building, “essentially we had to take off the exterior wall of the hospital and tie in at every floor level,” Light says.

The design team discovered that existing drawings were not as reliable as they had hoped, since areas abutting the addition were built at different points over the last 40 years, Fabre says. “Fortunately, we had enough slack in the edge condition between the new and existing buildings that it didn’t delay us too much,” Fabre says.

Additionally, since many of the air intakes for the existing air handlers were located on the windy side of the building where the contractor was working, “There was constant challenge early on to figure out how to prevent [work] fumes from getting into the building,” Light explains. Crews used other kinds of equipment, such as propane-powered machines and changed the way concrete was cured, switching from a spray-on curing seal to curing blankets.

But curing blankets can be flammable.

“We were welding on the floors above as the decks below cured, so we took extra precaution to wet the blankets down, reducing fire hazards, but still aiding the curing process,” Light says. “It was a difficult dance that didn’t always go as well as we’d like, but it was a very tough situation to be in to try to build something that’s the size that we were building and not have fumes.”

To measure moisture level in the concrete, the team installed Bluetooth-enabled concrete sensors on the rebar in the slab. They read moisture content as the concrete cured, allowing the team to identify issues in the concrete moving forward.

“One of the biggest risks in health care construction is flooring,” Cagle says. “We were one of the first projects in the company to use that technology. I think going forward it’s going to be huge value, especially in health care work in the industry.”

Manpower and Safety

With the hospital’s location in West Texas, the project team has been competing for labor with the oil fields.

“We probably maxed out at about 150 during our peak of the project, and that involved all 90% of skilled labor and 10% unskilled labor,” Salmon says. “With the temporary state of the oil field at one time during the project, we were able to get the labor force that we needed, but when that status changed, we lost them immediately. We were scrambling for additional manpower.”

The contractor had to bring in outside resources to supplement the team. “I would say we probably occupied at one point 50% of the hotels here,” Salmon adds.

As of Feb. 1, the project team had completed about 478,120 hours, with zero recordables and no lost-time incidents.

The project is currently on budget. The seven-story tower was completed and turned over in September, while the remainder of the project will be completed in late summer or early fall.

“I believe the most important thing in the beginning was creating the correct team to see this project through,” Droll says. “Our architect/MEP firm O’Connell Robertson helped us pick a contractor that would be a good partner. This partnership has gone a long way in making this project a success.”