Convergence of the ‘ologies’
As enterprise-wide digital information and image management systems replace paper and film, many traditional medical departments are evolving into multidisciplinary and interdependent services. The traditional “ologies”—radiology, cardiology, oncology, anesthesiology and, in particular, “surg-ology”—are being repackaged to become more collaborative and integral to uniting the healthcare spectrum. Much of this integration has been enabled by advanced, comprehensive medical data systems, with radiology driving much of the evolution.
The influence of medical imaging services throughout healthcare continues to grow, as myriad medical specialties increase their reliance on imaging data and as the rapid development of advanced communication systems continues to enable efficient decentralization of imaging functions. Furthermore, new hybrid combinations of imaging and nonimaging services, such as image-guided surgery (IGS), are resulting in novel facility designs, with imaging equipment incorporated into what have historically been nonimaging environments.
While image acquisition and interpretation have historically been the responsibility of radiologists, many other specialties now desire primary access to medical imaging equipment in order to control its use, interpret the images, and be financially remunerated for doing so. Equipment vendors market specialized devices customized for specific service lines, and some nonradiology specialists have purchased their own imaging equipment. For example, some MRI and multidetector computed tomography (MDCT) systems cater to cardiology, and some extremity magnets have been designed primarily for orthopedic applications. Intensivists in the Intensive Care Unit and emergency physicians in the Emergency Department frequently need to review diagnostic images before the radiologist has prepared an interpretive report. Some obstetricians operate their own ultrasound devices and interpret the images they acquire.
Facility design not only influences how well imaging equipment functions beyond the radiology department; the location and configuration of the imaging suite can also affect whether practitioners collaborate or compete for access. This, in turn, affects patient outcomes. Visionary planning may avert the costly duplication of space and equipment that might result from interdepartmental turf battles and, in the process, lead to fewer medical errors and preventable injuries.
Let's see how imaging capabilities have disseminated among specialties and what the design implications have been.
Imaging and Cardiology
Cardiac imaging includes noninvasive cardio-diagnostics and screening, invasive cardiac diagnostic and therapeutic imaging, and image guidance to support cardiovascular surgical procedures. These forms of cardiac imaging are performed in a variety of locations—hospitals, outpatient facilities, designated heart centers, and private physicians' offices. Some of the most significant technological advances regarding cardiac imaging are related to developments in molecular imaging (such as positron emission tomography [PET] and PET/CT), MDCT, dedicated cardiac MRI, magnetic resonance angiography (MRA), and ultrasound—especially ultrasound-activated microbubbles used for targeted drug and gene delivery.
Historically, both diagnostic and therapeutic cardiac exams have been routinely performed in cardiac catheterization and electrophysiology labs. However, advances in MDCT, computerized tomographic angiography (CTA), MRA, and cardiac nuclear imaging are shifting much of the diagnostic imaging load out of the cath lab and into less invasive CT, magnetic resonance (MR), and Nuclear Medicine environments. While many cath labs still perform both diagnostic and invasive procedures, the majority of cases is clearly shifting toward mostly invasive procedures and will continue to do so in the years to come.
The proliferation of advanced imaging systems used for cardiac exams, combined with strategic marketing of cardiac-specific imaging devices and imbalances in supply and demand for both interventional radiologists and cardiologists, has led to intense competition between these specialties. Competition for equipment ownership and patient referrals is compounded by varying opinions regarding who should read and interpret cardiac images. While most cardiologists claim they are more familiar with the nuances of cardiac anatomy and pathology, most radiologists believe they are more familiar with the subtleties of interpreting CT, MR, and nuclear medicine images and data. The designer needs to be sensitive to these turf battles to avoid being caught in the middle. Training in diplomacy will prove as valuable as training in health facility design.
Imaging and Oncology
While medical imaging is instrumental to many aspects of oncology, it is often most closely aligned with cancer screening, diagnosis, and various forms of therapy. Specifically, oncology-related imaging includes various screening examinations, diagnostic and staging examinations, computer-aided detection (CAD) tools, interventional oncology procedures, radiation therapy (RT) simulation, and radiation therapy treatment. Other specialty devices and procedures, such as gamma knives, cyber knives, and stereotactic radiosurgery, are also used in conjunction with oncology-related imaging. In addition, molecular imaging is instrumental in analyzing genetic and cellular structure, both to detect factors that may cause cancer and to treat cancer at a cellular level. The various forms of imaging used in conjunction with oncology treatment each have unique design requirements. For example, PET/CT—which has become increasingly popular since PET scans are now reimbursable—requires significant radiation shielding, requires quiet and dark patient holding rooms, and should be located so as to eliminate any unrelated through traffic.
The integration of medical imaging with RT and RT treatment planning creates opportunities for unprecedented collaboration among medical specialists. And, in contrast to cardiac imaging, advances in oncology-related imaging seem to foster collaborative relationships between oncologists and radiologists. Oncology imaging appears to make both specialties aware of the myriad opportunities each has to support the other. For example, radiologists use imaging technology to detect tumors, while oncologists and physicists use these tools to calculate treatment trajectories. Together they inform each other in a symbiotic relationship. In contrast, cardiologists may purchase their own CT scanners to compete with radiologists in performing similar procedures for the same patient.
Imaging and Surgery
Design of surgical suites capable of incorporating tomorrow's state-of-the art medical imaging systems is one of the most complex design challenges to be found within the healthcare environment. This is due in part to the diversity and intricacy of surgical procedures and the complexity of imaging systems used to support them. In addition to the typical design requirements of general imaging facilities, surgical imaging facility design must also meet the needs of infection control and restricted work flow to separate the flow of clean (or sterile) and soiled materials.
New types of personnel are becoming common in the collaborative surgical imaging environment. For example, as advanced imaging continues to become increasingly dependent on enhanced computing power, “surgical information technologists” are spending more time in the surgical suite. “Surgical imaging technologists” (similar to MR or CT techs in the diagnostic imaging department) are necessary to run complex image acquisition and transmission systems, as many surgical procedures become more reliant on image guidance. Some new operating room designs provide imaging control rooms to facilitate surgical image guidance and to better accommodate both surgical imaging technologists and surgical information technologists (figure 1).
ORs with control rooms
Minimally Invasive Surgery and Image-guided Surgery
Numerous surgical procedures these days are performed as minimally invasive surgery (MIS), an approach that has revolutionized surgery in recent decades. IGS systems, a common companion to MIS during neurosurgery and becoming more common in other types of surgery, integrate preoperative and intraoperative images with tracking technology that correlates surgeons' movements, thus enabling surgeons to observe their real-time location and orientation, and ultimately shorten procedure times and improve surgical outcomes.1
Operating room design needs to accommodate various forms of image reconstruction to help orient the surgeon. The placement of monitors displaying medical images in the OR is influenced by the type of surgical procedure being performed, who is using the images, and the types of images being displayed. The most up-to-date suites are now being designed with video routing equipment that can be controlled by the surgeon from within the sterile field. The surgeon has access to any medical data being created in the room during the procedure, and also has the ability to access data from electronic medical records, the picture archiving and communication system (PACS), or even remote sources from outside the facility.
Access to PACS images and other data within the sterile field can be provided in a number of ways. For example, some surgical suites use cart-mounted monitors—sometimes referred to as COWs (computers on wheels)—while others incorporate wall-mounted displays. Use of computer carts can result in a plethora of interconnecting wires and cables posing a safety hazard, and even bring contaminants into the sterile field.
While wireless computer systems reduce the number of cables needed, they do not eliminate them entirely. Alternatively, wall-mounted displays (either surface mounted, or on articulating arms), while eliminating many of the cables, are inflexible and cannot be as easily moved. They must also be large enough to be viewed from a distance.
Displays on ceiling-mounted booms with articulating arms— another alternative—are easily movable and don't require distance viewing. However, the booms may interfere with the movement of other ceiling-mounted devices, such as surgical lights, anesthesia equipment, and radiation shields, unless the path of travel for each device in the room is carefully coordinated. In addition, fixed-boom locations that are ideal for one type of procedure may not work well for others. The placement of ceiling booms is therefore challenging for designers of “universal” ORs intended to accommodate any type of surgical procedure. While no solution is ideal, the preferred approach for most ORs is ceiling-mounted towers on flexible booms. The type and size of the OR will determine the number of booms (typically two or three) and their location.
Often, a pair of ceiling-mounted flat-panel monitors provides surgeons with a view of what is visualized through the laparoscope, and an additional wide-screen flat-panel monitor affixed to one wall of the OR (mounted at standing height eye-level) can help orient the entire surgical team with various forms of image guidance. In addition, some surgeons wear special headsets or goggles that project a view into their visual field, and some institutions are experimenting with virtual, or augmented, reality by projecting anatomical images onto the patient, giving the illusion of being able to “see through” the patient as an alternative means of image guidance.
Since the surgical team is performing arduous, slow, and delicate manipulative procedures, while indirectly viewing their actions via an array of monitors, proper ergonomic and human-factors design is essential for the physicians' comfort and safety. Moreover, lighting design requirements for the OR are complex and often contradictory. For example, lighting must be dimmable where images are projected on monitors, yet other surfaces in the OR, such as the surgical site, must be highly illuminated. Ambient lighting in the operating room cannot be too dim because ample lighting is still required for the various activities taking place, such as nurses circulating about the room and equipment and supply movement.
Some surgeons and radiologists are focusing attention on performing surgical procedures under MRI guidance. This concept is sometimes referred to as Magnetic Resonance Therapy (MRT) or Intraoperative Magnetic Resonance Therapy (I-MRT). MRI has a unique ability to distinguish between healthy and abnormal tissue due to its sensitivity to changes in tissue temperature.2 Under MR guidance, surgeons can operate very precisely when a tumor's margins are clearly defined. Numerous types of magnets and various facility configurations have been developed for I-MRT. Each requires unique design considerations, and each has it own set of advantages and disadvantages. Some enable surgical procedures to be performed within the 5 gauss line of the magnet but are limited by the lack of MR-compatible surgical instruments. Others allow surgical procedures to take place beyond the 5 gauss line but require complex transport of the patient from one side of the room to another. Still others enable the magnet to move from one place to another, allowing the patient to remain stationary while surgical procedures are performed outside the magnet's strong magnetic field. Each of these various concepts requires a customized approach to magnetic and radio frequency (RF) shielding. Each poses unique challenges for creating a safe environment that guarantees that non-MR-compatible objects cannot enter the magnet's field.
Blurred Boundaries Between Surgery and Interventional Radiology
Many surgical procedures that were traditionally performed exclusively within an operating room are now routinely performed within a variety of advanced procedure rooms. And many of the diagnostic procedures traditionally performed within interventional procedure rooms are now being performed in the diagnostic imaging environment.
The nature of procedure rooms themselves is becoming more flexible. For example, cardiac cath labs and peripheral angiography rooms tend to be similar in how they are designed, but they used to be somewhat dissimilar in how they were equipped. When imaging equipment was analog-based, each room had a different sized image intensifier—one sized for detailed cardiac procedures, and the other for broader peripheral procedures. However, today's digitally equipped rooms benefit from new flat-panel detectors that can accommodate both cardiac and peripheral procedures.3 Thus, one room can be used for a variety of procedure types and can change function either on a daily basis or have its workload adjusted over a period of months or years. This approach to universal room design is a first step to increasing flexibility and minimizing turf battles among specialties. With innovative planning and skilled diplomatic leadership, a universal approach can be used to design a common footprint accommodating a wide range of surgery, interventional radiology, and interventional cardiology procedures (figure 2). It warrants invention of an integrated interventional platform—a new approach to both room design and departmental design anticipating new types of equipment and new roles for personnel, as well as changes in work flow, in an overall more collaborative environment.
An integrated procedural floor
For example, more stringent flow control for interventional imaging environments and more lenient rules for configuring surgical suites are resulting in newly emerging layouts that are applicable to both service lines. This new planning model includes pods of procedure rooms surrounding a staff core and control rooms (similar to those used to support the cath lab or angiography room), as well as procedure room pods with a clean supply core in the center (figure 3). As both imaging and surgery become more computer-driven, and as advanced image and information systems become more integral to both imaging and surgery, computer-server cabinets within the vicinity of the procedure room have become necessary. These cabinets are often better located directly adjacent to the procedure room rather than within it. Ideally, the server cabinets can be placed near the central staff core/control area.
Procedure room pod designed to be used for either surgery, interventional radiology, or interventional cardiology
Another advantage of the integrated interventional platform, where operating rooms, interventional rooms, cath labs, and even endoscopic suites are collocated, is that scarce patient preparation and recovery space, personnel, and equipment can be consolidated in a flexible configuration that supports multiple service lines, rather than duplicating these areas in separate locations. The overall prep/recovery area still needs to be sized appropriately for the comprehensive number of surgical, interventional, cath, and endoscopic prep/recovery positions required, but these should be configured as flexible but intimately scaled modules.
Compared with separate decentralized surgical, interventional, cath, and endoscopic recovery suites, prep/recovery zones within the comprehensive centralized suite can “swing” more easily to accommodate varying census volumes. In addition, recovery staff may become more cross-trained to support myriad patients' needs, including both cardiac and surgical patients.
The integrated interventional platform is a planning framework designed to support a diverse array of procedures in universally designed procedure rooms. The integrated interventional platform assumes that the operating room of the future may look and feel more like today's catheterization lab (with electronic equipment and a control area adjacent to, but separate from, the procedure room itself) than like yesterday's operating room (with only minimal provisions to integrate image guidance and data management into the surgical procedure). In addition, the integrated interventional platform anticipates that advanced forms of image guidance not yet available today will eventually need to be assimilated into the suite with minimal disruption of ongoing services. Thus, procedure rooms are clustered together for the future conversion of adjacent rooms into hybrid configurations, such as intraoperative MRI/ORs or MRI/PET/ORs.
Imaging and Surgery in the Future
According to Richard Satava, MD, a visionary surgeon at the University of Washington and a pioneer in the U.S. Department of Defense's development of advanced robotic surgery and virtual telepresence surgery (where patient and surgeon can be in two separate locations), developments in surgical training using simulation to practice surgical technique will radically affect both surgical procedures and surgical facility design. Accordingly, patients will undergo a comprehensive total-body scan prior to their surgical procedure, which after postprocessing will become a dynamic patient medical record. Using this dataset to rehearse the surgical procedure, surgeons will hone their skills on surgical simulators, editing out their mistakes, in much the same way we currently edit text in word processing software to “perfect” a written manuscript.4
“The scenario will be one in which the surgeon performs the virtual operation on the patient's image, ‘edits’ the procedure until it is perfect, then pushes the ‘operate’ button, and a ‘perfect’ operation is performed, with all the errors edited out,” Satava writes. “This will take surgery from the Industrial Age, or ‘typewriter mentality’ of today and into the ‘word processor’ stage of the Information Age.”4
In this scenario, the advanced anatomic and physiologic image-acquisition and monitoring systems discussed in this article become a virtual electronic patient record, upon which the surgical procedure is choreographed.
With total-body scanning or organ-specific scanning, it is possible to get an information representation of the patient. Thus, preoperative planning, surgical rehearsal, intraoperative navigation, and postsurgical outcomes can all be automatically integrated through the use of the robotic system. The robotic system is not a machine; rather, it is an information system with “arms.” And a computed tomography scanner is not an imaging system; it is an information system with “eyes.” Thus, the entire spectrum of surgical care, from preoperation to postoperation, can be integrated in “information space” to enhance surgical care in “real space.”4
Realizing this vision will take careful, well-informed work by healthcare designers moving us into this new era of imaging technology. HD
Adapted with permission from the forthcoming book The Architecture of Medical Imaging: Designing Healthcare Facilities for Advanced Radiological Diagnostic and Therapeutic Techniques, by Bill Rostenberg, FAIA, FACHA, scheduled for publication in mid-2006 by John Wiley and Sons, Inc.
Bill Rostenberg, FAIA, FACHA, is a Principal and Director of Research in the San Francisco office of Anshen+Allen Architects. An author of numerous books and articles on health facility design, Rostenberg frequently speaks to both medical and design professionals, such as The Radiological Society of North America (RSNA), The Society for Computer Applications in Radiology (SCAR), OR Manager, The Association of periOperative Registered Nurses (AORN), The American Hospital Association (AHA), The American Institute of Architects (AIA), and Harvard University Graduate School of Design—Office of Executive Education.
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- Chesson E. Viewing images in the OR. Health Imaging & IT 2004; 7:40-44.
- Hodder HF. Bloodless Revolution: Twenty-first-century surgery. Harvard Magazine 2000; 103 (2): 36-40.
- Fratt L. Inside the state-of-the-art cath lab. Health Imaging & IT 2006; 3:22-26.
- Satava RM. The operating room of the future: Observations and commentary. Seminars in Laparoscopic Surgery 2003; 10 (3): 99-105.
Healthcare Design 2006 May;6(3):42-54