Ask the team of doctors and healthcare architects who recently designed a totally new neurosurgical environment in Arizona about the level of detail and flexibility involved in a breakthrough project of this type and they'll tell you it's a lot like, well… brain surgery. A delicate balance of intelligence, skill, and creativity led Carondelet Neurological Institute (CNI) at St. Joseph's Hospital in Tucson, Arizona, to be the nation's first healthcare facility to feature a technically advanced neurosurgery suite of operating rooms that combines a two-room interconnected intraoperative surgical platform for complex brain surgery. The room features a first-of-its-kind gantry-mounted sliding CT scanner that moves between the two rooms, taking the technology to the sedated patient rather than the patient to the machine. HuntonBrady Architects of Orlando, Florida, BrainLAB Inc., and Siemens teamed to make this project a success, which stands to revolutionize neurosurgery OR design.

“When Carondelet Health Network first explained that they would like to incorporate a CT on rails to serve two adjacent neurosurgery operating rooms, I have to admit I was a bit skeptical,” explains Paul Macheske, AIA, ACHA, project manager for HuntonBrady Architects. “My formative years in healthcare design led me to believe that first of its kind technology in hospitals surfaced at academic medical institutions, not in community hospitals.”

What propelled this solution to be fully realized at St. Joseph's Medical Center was, at the heart of the project, a champion: the Medical Director of the Carondelet Neurological Institute, clinically active neurosurgeon, Eric Sipos, MD. He had great aspirations, the backing of administration at St. Joseph's Medical Center, and a true desire to improve patient outcomes.

“Dr. Sipos embraced the design process and, in turn, we assembled a collaborative, interdisciplinary team to plan and design a totally new neurosurgical environment,” Macheske explains. In addition to HuntonBrady Architects and consultants, this team included Carl Colombi of BrainLAB, a technical consultant for integrated OR solutions who had responsibility for the cohesion of the integration and navigation systems for the ORs, the surgical tables and CT scan, and overhead lights and booms.

While CTs in operating rooms are not uncommon, they are relatively rare because of the cost. And most hospitals cannot afford to place multiple CTs in operating rooms. Carondelet neurosurgeons and administrators challenged the team to design a functional, flexible, cost-effective, and safe suite in which to perform a high volume of specialized neurosurgical procedures. Their solution allows the CT to be used in two adjacent operating rooms: as one room is being cleaned between cases, the CT can roll into the second OR. When not in use, the CT is parked in the CT “garage.”

The business case for safer surgeries

“Our business case for the new image-guided neurosurgery suite at Carondelet Neurological Institute was focused on safer surgeries,” explains Dr. Sipos. “The dual-room provides surgeons with real-time, decision-making information to treat complicated and routine cranial and spinal procedures, such as tumors, aneurysms, vascular malformations, spinal fusions, and minimally invasive spine procedures. And by combining image-guided surgery, intra-operative CT, data management, and visualization technology, we have immediate access to new images of the brain and spine before, during, and at the conclusion of the surgical procedure.”

Located between the two ORS in a space similar to substerile space that is used for other types of operating equipment, there are two sets of custom sliding lead-shielded doors, each of which opens to one of the ORs. Structural coordination was required to stress the facility to accommodate the weight of the CT, insert the rails on which the CT gantry travels and minimize the vibration of the gantry's motor drive unit. A single CT control room is situated to provide visibility into either OR.

The nation's first dual-room intraoperative CT/OR with sliding gantry at Carondelet Neurological Institute in Tuscon, Arizona
The nation's first dual-room intraoperative CT/OR with sliding gantry at Carondelet Neurological Institute in Tuscon, Arizona

Carl Colombi of BrainLAB explains: “The navigation system links the real-time intra-operative images with the spatial position of the surgical instruments offering a higher level of accuracy regarding location and amount of tissue removed. In addition, the intraoperative CT images fused with pre-operative MRI images help neurosurgeons determine more accurately whether the appropriate amount of diseased tissue has been removed.” At Carondelet, this has reduced the need for a later re-operation.

Choice of imaging modality: CT versus MRI

Ask nearly every radiologist, design professional, and neurosurgeon, and you will likely find that MRI is considered the gold standard for soft tissue capture, but it presents challenges to a surgical environment.

Dr. Sipos says, “From our perspective, CT was a better solution for an intra-operative imaging system for a number of reasons, including acquisition cost. CT technology is typically less costly than MR technology. We were also mindful of training requirements. Unlike MRI, CT would not require our staff to rethink their procedures, stay outside of a magnetic field, or conduct specialized training.”

The surgeons and hospital also recognized that CT presented a much lower risk for potential accidents in a surgical platform. Between 2003 to 2008, MRI accident rates increased from 35 to 150, according to the U.S. Food & Drug Administration.

HuntonBrady's research also showed that a two-room MR/OR requires significantly more space than a two-room CT/OR. Excluding circulation and typical OR support, a two-room CT/OR suite requires 2,060 to 2,400 net square feet, whereas a two-room MR/OR suite requires 3,210 to 3,485 square feet. The approximately 1,100 additional square feet is needed for the center “MR Park” area which becomes a diagnostic room, and the location where the magnet rotates and the cryogen vent “umbilical” is located. Based on hospital cost per square foot, this choice is significant.

Architectural challenges

There were many architectural challenges to a healthcare project as novel as Carondelet's. There were no design models for a two-room CT/OR with sliding gantry. The closest reference was an Alpha Site at Gross-Hardin in Germany.

It was critical to ensure the patients in the adjacent OR's were not compromised by one piece of technology jointly shared between them. To resolve this, the architect developed the concept of a “CT Park” between the ORs where the CT equipment would be stored when not in use. An interlock was incorporated into the custom, automatic, horizontal-sliding, lead-lined doors that contained this space so one side could only open at a time to prevent crosscontamination.

“There were a lot of moving parts to coordinate,” Macheske explains. “The CT moves on a floor rail system, which also had an overhead motorized carrier for cabling. Automatic, sliding lead doors separated the rooms and had to cantilever at the intersection with the carrier, which dropped below the ceiling by one foot and works as top-hung only. Lights, booms, and the table base had to avoid collision with the CT.

The hospital and neurosurgeons wanted a fully integrated intraoperative CT surgical operating room with an image guidance system built into the surgical suite
The hospital and neurosurgeons wanted a fully integrated intraoperative CT surgical operating room with an image guidance system built into the surgical suite

“We were sensitive not to make the motorized carrier look like an afterthought and designed this into the overall ceiling composition,” adds Macheske.

Design evolution

The project went through a series of evolutions before the final plan was set. Initially, it began as a fixed CT in one OR with control having line of sight to the head. The other two ORs had a classic arrangement of substerile space between the pair of procedure rooms. All ORs were 800 square feet. When BrainLAB became involved, the concept changed to a dual-room CT/OR solution. The final solution narrowed the CT park area and located control parallel to the movement of the CT.

Project schedule

Keeping a project of this magnitude on schedule was foremost. The architect recommends early involvement of the equipment, integration and navigation vendor to save time during the design phase. Commitments for vendor drawings and release of hospital purchase orders are essential to the design schedule. “Plan on having CT rails on site and protected three months into construction and allow sufficient time for installing, testing, and calibrating the equipment,” Macheske says.

As for cost, the project came in under the $13.5 million project budget that was established, which broke down to roughly $4.5 million per operating room (a third room was included in the scope). What was enlightening, and certainly atypical, is that 65% of the costs were dedicated to equipment.

The neurosurgeons and design team investigated the ability to install a CT on a sliding gantry that moved between two operating rooms with a CT “garage” located between the two rooms for safe storage when not in use.
The neurosurgeons and design team investigated the ability to install a CT on a sliding gantry that moved between two operating rooms with a CT “garage” located between the two rooms for safe storage when not in use.

Conclusions

The experience of designing the first dual room, intra-operative CT/OR with a sliding gantry led the architect and owner to conclude some key lessons learned.

Designing a successful, high-performance neurosurgical environment involves a robust project budget, an actively-involved physician champion, and a collaborative interdisciplinary owner/architect/contractor/vendor team
Designing a successful, high-performance neurosurgical environment involves a robust project budget, an actively-involved physician champion, and a collaborative interdisciplinary owner/architect/contractor/vendor team

First, plan for a robust project budget and ensure all options are fully understood. Be wary of historical cost per square foot approach to budgeting and project budget development without specific equipment basis. Second, define a clinically active physician champion for the project; one who embraces technology and the design process. Third, identify a collaborative, interdisciplinary owner/architect/contractor/vendor team to fully work through all details of the project. Avoid the “us” versus “them” mentality. And finally, make major design, equipment, and clinical decisions early and develop the schedule around vendor-drawing development. On a project such as this, architecture is the integral wrap around the technology. HD

Practical Area Recommendations for a Two-Room Neurosurgical CT/OR

Much has been publicized about the concern over super-sizing healthcare. HuntonBrady Architects sized the Carondelet spaces based upon function, required equipment, and workflow. From a clinical perspective, the neurosurgeons and OR staff have validated that the rooms were right-sized-not too big, not too small. Excluding typical support common to all ORs (equipment, clean supply, soiled, circulation, etc.), the firm recommends the following metrics for space allocation of a two-room neurosurgery operating room:

CT/Operating Room

710-750 square feet (x 2)

CT Park

80-100 square feet (4′ w)

CT Control

170-200 square feet

CT Equipment

30-40 square feet (4′ w)

Nav./Integration Equip

80-100 square feet

Scrub and substerile

140-230 square feet (x 2)

TOTAL=

2,060-2,400 net square feet

Paul Machesk, AIA, ACHA, LEED AP, NCARB, is Director of Healthcare Design and Lorie Matejowsky is Communiciations Manager for HuntonBrady Architects, an award-winning Orlando-based architecture and interior design firm founded in 1947.

For more information, visit http://www.huntonbrady.com.

Healthcare Design 2010 January;10(1):38-42