Nearly two decades ago, leaders at the Medical University of South Carolina were faced with a decision. 

The hospital's facilities on the peninsula would eventually need to be replaced. 

The children's hospital was still relatively new — it had been built in the 1980s — but the main hospital opened its doors to patients in 1955. 

Sooner rather than later, the buildings would need to be upgraded. 

But where to replace them? The question yielded a long-term hospital replacement plan rooted in an early, important choice: Keep the buildings on the peninsula. 

And the exercise bore fruit. 

In 2008, the $275 million Ashley River Tower opened on Courtenay Drive, dubbed by The Post and Courier the "Hospital of Tomorrow." The 641,000-square-foot building, with its eight-story glass "sail tower" was hailed as an architectural feat, transforming the face of the blocky medical district.  

Next came a plan to replace the children's hospital.

In 2013, hospital board members approved a plan to proceed with the construction of a new building on the corner of Calhoun Street and Courtenay Drive. It would bear the same look and feel of the adjacent Ashley River Tower. 

Five years later, the $385 million MUSC Shawn Jenkins Children's Hospital is set to open this fall. It will be the most expensive hospital ever built in South Carolina. 

“Imagine what’s going to rise from that place, the impact that it’s going to have for our children in the future,” MUSC President David Cole said when the project broke ground in 2016. “It will, without question, change the landscape of health care in South Carolina for future generations to come.”

With that project nearing completion, hospital leaders have set their sights on the next phase of the hospital replacement plan. It has yet to be formally announced, but hospital leaders recently told The Post and Courier they intend to replace the main hospital on the Ashley Avenue horseshoe with a new building somewhere west of Courtenay Drive.

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MUSC plans to move all clinical adult care, including trauma services and neurosciences, out of the existing main hospital. 

"There's only so much you can do in a 60- to 70-year-old building," said Dr. Pat Cawley, CEO of Medical University Hospital. 

The new building, Cawley said, may not be complete for another decade, but he anticipates it will be bigger than Ashley River Tower and the new children's hospital, and that it will be designed to care for patients with the most critical needs. 

Increasingly, health care will be administered remotely via telemedicine, Cawley explained. Ten years down the road, fewer patients will need to be admitted to a physical hospital. Inpatient beds will be reserved for the gravest cases. Every room in the new hospital will be equipped and staffed nearly at the level of an intensive care unit, he said. 

"The last phase is going to be a building with very, very sick patients," he said. 

It's not clear what the new main hospital will look like, exactly where west of Courtenay Drive it will be located or — perhaps most importantly — how much it will cost, but in the meantime, MUSC is busy expanding elsewhere. 

MUSC leaders plan to build a new $325 million hospital just off Interstate 26 in Berkeley County and were approved last week to spend up to $137 million on four rural hospitals in other parts of the state. 

Reach Lauren Sausser at 843-937-5598.