Integration: Creating an integrated service for traditionally disparate departments
Rapidly developing technologies and medical advances are blurring the boundaries between surgery, interventional radiology, and cardiology. These traditionally separate disciplines are performing both diagnostic and therapeutic procedures requiring similar equipment, technologies, and spaces. Many surgical procedures benefit from the use of advanced imaging modalities, and many imaging studies have integrated surgery-type therapeutic interventions. Research has shown clear benefits from designing adaptable environments that integrate these three key hospital services, resulting in more efficient use of staff and space, and providing a standardized level of patient care to increase patient safety.
During programming of a 12-story, 350-bed replacement hospital for Providence Regional Medical Center in Everett, Washington, the client responded to this trend toward integration by combining these three hospital service lines to create a 120,000-square-foot Integrated Surgical Interventional Service, using 28 generic (“big box”) rooms. As the project proceeded through master planning and conceptual design, the design team determined that, with the limited available site, the integrated program would not fit on one floor. Therefore, the 28 procedure rooms were conceived of as universally designed big box rooms, each programmed at 700 net square feet to provide flexibility. The preferred planning solution split the big box rooms onto two floors, with 12 rooms on the lower level and 16 on the upper (figures 1, 2).
Section stacking diagram for Providence Regional Medical Center in Everett, Washington
Stacked floor plan for the Integrated Surgical-Interventional Service
Based on these initial programming efforts, the design team identified three key planning concepts:
both floors should have the same organizational zoning in order to standardize the flow of patients, families, staff, information and materials;
all operating and procedure rooms should be located around cleans cores that are stacked to provide direct vertical elevator access to the sterile processing department located on a lower floor; and
locker facilities should be consolidated on one floor, with a dedicated staff connection to the other floor to address physicians' practice patterns.
Collaborative planning exercises helped build consensus and support for the new model of care and implement the necessary cultural and organizational change. The team of designers and medical planners worked closely with surgeons, radiologists, cardiologists, anesthesiologists, nurses and technicians to explore and outline design and operational opportunities and develop initial design concepts for discussion during interdisciplinary user group meetings. Enlarged color-coded floor plans, 3-D modeling, and a semitransparent “resistor” model (figure 3)-stacked plexiglass floor plates laminated with color floor plans to illustrate dimensional relationships between services and routes for patients, staff, and materials transport-were some of the tools that helped users visualize the space and physical relationships of the program components and served as the basis for resolving interdisciplinary operational challenges.
A semitransparent “resistor” model-stacked plexiglass floor plates laminated with color floor plans to illustrate dimensional relationships between services and routes for patients, staff, and materials transport-was one of the tools that helped users visualize the space and physical relationships of the program components
Multidisciplinary “tabletop” workshops (figure 4) provided forums for discussion and review of planning proposals, and helped build agreement among this diverse clinical group. Typical surgery, CVL, and interventional radiology schedules were simulated and the users walked through routine and emergency scenarios to test the flow of patients, families, caregivers, supplies, and information within the spaces. Gaming pieces on the table tops allowed individuals to try new ideas and receive feedback from the differing perspectives of specialists. For example, rapid access to a cardiac catheterization lab from the emergency department and direct access from the lab to a cardiac operating room were of primary concern. During the tabletop exercise multiple arrangements were explored, and a consensus was reached to colocate a cath lab and a cardiac OR with direct access from the patient transport elevators, thus speeding up patient transport from the emergency department.
Multidisciplinary “tabletop” workshops provided forums for discussion and review of planning proposals, and helped build agreement among this diverse clinical group
Feedback from these multidisciplinary planning exercises helped the design team assign specialty ORs to specific locations and identify key intradepartmental relationships. As a result, the first level of the integrated service contains 12 operating rooms arranged around two clean cores and functions as a typical surgery floor for general, gynecology, ENT, plastic, and orthopedic cases. The second level contains 16 big box rooms, including the cardiac, neurosurgery, and vascular operating rooms, cardiac catheterization, interventional radiology, and electrophysiology labs, arranged around two clean-cores.
Integration of three disciplines in a surgical environment promotes adherence to the same standards for facilities, patient flow, and sterile techniques. Performing procedures within a surgical environment presents a fundamental change for cardiologists, requiring them to adhere to surgical protocols when entering the restricted environment. Thus, locker rooms located on the second level of the integrated service provide a quick and convenient way for physicians and staff to change into scrubs. A consultation room outside of the restricted zone allows physicians to view images and collaborate with colleagues outside of the surgical environment.
The integrated service also supports standardized patient care, which has been shown to improve patient safety and clinical outcomes. A Preoperative/Phase II Recovery Unit on each level provides private rooms for all patients, including space for family members during preprocedure preparation, secondary recovery, and discharge. Directly adjacent, a Post-Anesthesia Care Unit (PACU) contains Phase I recovery bays arranged to allow direct visual supervision of every patient position.
Careful attention was paid to the patient and family experience, providing a seamless flow from arrival through preparation, procedure, recovery, and discharge/admitting. Reception and family waiting areas are located to take advantage of the mountain views to the north, offering a calming environment for patients and their families. Amenities including a resource center, children's play area, private consultation rooms, and kitchenette are available for families and loved ones waiting during long surgery and recovery times. Electronic patient tracking boards will enable families in the waiting room to monitor the progress of their loved one from surgery to recovery. Three check-in stations speed the registration process where the patients only need sign a consent form and receive a wrist band; all other preparatory work is completed before arrival.
All operating and procedure rooms contain fully integrated audio-visual (AV) systems, providing physicians and surgeons with access to PACS for both real-time and prior imaging studies, and additional clinical information such as laboratory results, while performing procedures. Information will be displayed on both boom-mounted and large, wall-mounted monitors, with physician control of the display of information from a boom-mounted touch-screen monitor from within the sterile field. Provisions to transmit images of procedures to outlying conference rooms for interdisciplinary discussion and analysis are also provided.
Hybrid Vascular OR
One design challenge unique to this service was the Hybrid Vascular OR (figure 5), including both imaging and surgery capabilities in one suite of rooms, which allow for real-time imaging during complex vascular surgical procedures. Complexities involved both the functional layout of the operating room and the technical coordination of the equipment and infrastructure. The major pieces of equipment in this room include a single-plane interventional imaging system (c-arm), an imaging-capable surgical table, and ceiling-mounted surgical lights and equipment booms.
The Hybrid Vascular OR includes both imaging and surgery capabilities in one suite of rooms
The main planning challenge for the Hybrid Vascular OR rooms was resolving the spatial relationship between the surgical table in the surgery position and the location of the single plane c-arm in the parked position to provide sufficient clear floor space for the anesthesiologist and equipment near the head of the surgical table at all times. The resulting layout placed the axis of the surgical table parallel to the OR walls with the axis of the c-arm rotated 30 degrees clockwise; the surgical table can be rotated to align with the c-arm axis for imaging studies.
Technical coordination focused on the ceiling and on resolving the clashing geometries of the supply air diffusers, room lights, surgical lights, and equipment booms, which had been placed to support surgery with the unistrut support system and equipment rails of the c-arm. Solving both the planning and technical coordination issues posed by this required many face-to-face meetings involving clinical users, the architects, consulting engineers, contractors, and equipment vendors and is an example of a proactive, collaborative design effort.
Design of this highly technical procedural medicine environment to enhance collaboration between surgeons, interventional radiologists, and cardiologists resulted in a facility that will be flexible, efficient, and will increase patient safety and therapeutic experience. This integrated model of care required significant changes in existing operational practices and culture and would not have been possible without the vision and leadership from the Providence Health and Services executive team, key physicians, and department heads. It is our hope that successfully pioneering this integrated service within the Providence organization will set a precedent for designing integrated Surgical-Interventional departments now and in the future. HD