The current Martha's Vineyard Hospital building no longer offers adequate capacity and is in its final stages of usefulness, hospital officials told members of the Martha's Vineyard Commission last night.

The remarks came during a marathon five-hour session that kicked off the formal public hearing process for the proposed $42 million hospital renovation and expansion project, which the commission is reviewing as a development of regional impact (DRI).

Hospital officials made their case to the commission that they must upgrade the facility in the Eastville section of Oak Bluffs in order to remain a fully functioning emergency health care operation. Board of trustees vice chairman Timothy Sweet said plans for the new building were spurred by the financial crisis ten years ago that forced the hospital into bankruptcy. The last few years have seen a marked change at the hospital in terms of profitability and overall stability.

"Like all near-death experiences, ours was transforming . . . It gave us a renewed appreciation for how important this hospital was for the Island," Mr. Sweet told the commission last night. "We reside on an Island three miles off the coast, so there are always going to be moments when our lives depend not only on the existence, but also the quality, of our hospital."

Mr. Sweet argued that the proposed expansion project is an important step forward for the Vineyard as a whole.

"We believe it is safe, sensitive to the environment, and wholly beneficial to the community it serves," he said.

Hospital officials have worked with the commission informally for almost two years, incorporating a number of design recommendations along the way. But last night marked the official start to the formal regulatory process, and brought with it an air of anticipation.

Held in the Martha's Vineyard Regional High School cafeteria, nearly a dozen hospital representatives lined up in the front row, including a series of experts and consultants who offered Power Point presentations on different aspects of the project

Also in attendance were about 20 members of the general public and a dozen Oak Bluffs town officials. Though expressing some minor concern, town officials who spoke last night were almost unanimously in favor of the proposed project.

"Our hospital is in disrepair, as we all know, and is plain worn-out," said Oak Bluffs selectman Roger Wey. "We cannot afford to wait any longer. The Island needs and deserves a new hospital. Not ten years from now, but now."

Members of the general public were not permitted to speak at this session, the first of three, but are invited to do so at the second hearing scheduled for next Wednesday night at the Katharine Cornell Theatre in Vineyard Haven. The commission hopes to close the public hearing after a third session on Thursday night at the Old Whaling Church in Edgartown.

If approved by the commission, the hospital project will also need permits from the Oak Bluffs conservation commission, planning board and zoning board of appeals. Construction managers for the hospital expansion said last night that they hope to beak ground in March and complete the entire project by August 2009.

The project aims to renovate, expand and replace the aging 1972 hospital with a state-of-the-art, green-designed facility. The proposal would increase the total number of hospital beds from 15 to 24, and would house all of the inpatient rooms and emergency and surgical services in a new 90,000-square-foot, two-story addition. The facade of the original 1929 cottage hospital building would be demolished, and the 1972 wing would be renovated to house physician and administrative offices.

Much of the discussion between commission and hospital officials over the last two years has focused on the trustees' decision not to pursue an alternative location for the hospital site. Hospital chief executive officer Timothy Walsh reiterated last night that the choice was a matter of economics, estimating that such a move would add as much as $30 million to the overall project cost, not including the cost of further delays.

Mr. Sweet announced that the hospital building campaign has topped the $38 million mark in private donations and is nearing completion in what has been the largest capital fundraising campaign in Island history.

Some commission members and other Vineyard residents have suggested that the current 13-acre hospital site is environmentally sensitive, too small for future expansion, and overly susceptible to the risk of flooding during hurricanes or other large coastal storms.

The commission and hospital hired a third-party coastal engineering consultant, Woods Hole Group of East Falmouth, to prepare a risk assessment study of the proposed project.

The near-final report, presented last night, found an overall low risk for the project on its current site, noting that storm surges and flooding would affect access to the hospital but not the building itself. The study proposed three mitigation measures to resolve the partial compromise of operations during a Category Three storm event, which has a roughly 2.5 per cent chance of occurring in any given year.

Woods Hole Group geologist Leslie Fields said last night that the hospital would likely cease operation during a Category Four storm event, but noted that such an event has only a one per cent chance of occurring any year, and has yet to take place in New England. She added that Massachusetts alone has more than 20 hospital facilities located within possible flood zones.

But Dr. Martin Crane, a mainland physician and the governor's appointed member to the commission, noted that the Vineyard hospital will likely face extenuating circumstances in a true emergency.

"For evacuations, this hospital depends on an airlift - which is something specific to this Island hospital that is separated from the mainland," Dr. Crane said. "Did you factor that risk into your analysis?"

Ms. Fields said that she had not, and acknowledged that he had made a good point.

Most of the commission questions focused on the design of the new 90,000-square-foot addition. To comply with one of the risk study recommendations, project architects said they would switch the proposed exterior of the building from gray cement siding to brick.

Commission members did not appear thrilled at the prospect. One asked if the hospital would seek the advice of the Oak Bluffs historic commission, but Mr. Sweet said the trustees went through a similar process for the Windemere Nursing Home and Rehabilitation Facility 15 years ago, and ended up with a compromised project.

He suggested that the commission might simply have to accept that large institutional buildings are out of character with general Vineyard architecture.

"The word impossible is not wrong here," Mr. Sweet said. "You can't make it into something it ain't."

A similar discussion ensued regarding energy efficiency and environmentally friendly building practices. Hospital architects have registered the hospital plans with the United States Green Building council in the LEED (Leadership in Energy and Environmental Design) certification program, but commission members urged them to explore obtaining a higher level of LEED status. Hospital architects said health care facilities face enormous challenges in green building design - there are only two LEED certified hospitals in the country, and none yet in Massachusetts.

The hearing will continue next Wednesday at the Katharine Cornell Theatre. The session begins at 8 p.m.