How do you internally renovate and expand the only Level 1 trauma center in the region without affecting its ongoing operations or capacity? Carefully, by selecting the right team and the right process! Completed more than 30 years ago, the Trauma Center has changed little over the decades as codes and technology progressed exponentially. The community has grown much faster than anticipated when the original trauma bay was designed to treat 1,000 patients annually; now, more than 5,100 patients are treated annually. To keep pace with growth, the design of the emergency department exam rooms maintained 30 and expanded trauma bays from 5 to 6 with a surge capacity to double when required. The hospital’s adjoining emergency department was expanded a few years ago, encapsulating the trauma center and leaving no direction to expand outwardly without shutting down ongoing 24-hour operations. To further complicate matters, the design took place in the midst of the COVID-19 pandemic, with the medical staff overworked and with scant time to participate in solving this complicated problem. The solution was a unique charrette process that visualized the potential design options three dimensionally in real time so that all parties (user, builder, designer) could understand the issues and rapidly come to consensus. This process included identifying and placing medical equipment in real time based on the client’s feedback and requirements. The strategy also helped the team develop a path to phase the construction while not reducing the number of beds or the capacity of the care unit. This presentation addresses a variety of strategies and lessons learned in the design, operations, construction and schedule/budget while delivering this complex project. Core Competencies: Strategic Planning; Space Planning and Programming; Design; Equipment Planning; Equipment Acquisition; Transition Planning AIA Course Number: 2023.05.009 AIA CEU = 1 LU