The OR theater of the future
When 13-year-old Nichole Paone recently had to undergo surgery to remove a tumor the size of a baseball at the back of her brain, she was operated on in Children's Hospital Boston's new MROR, the world's first Intraoperative Magnetic Resonance Imaging (MRI) operating room of its kind.
While most healthcare architects know that healthcare design must continually reinvent itself as a flexible and adaptable environment to accommodate rapidly changing technology, many designers have not yet encountered or anticipated the inevitable and dramatic technologic changes that are taking place in the OR, where imaging, robotics, and other technologic advances have ramped up the need for specialized, multidisciplinary planning, design, engineering, and management.
The MROR in Action
In the new Clinical Building Expansion at Children's Hospital Boston, what might have been seen as science-fiction technology a few years ago has become reality. With the intraoperative MROR, a standard operating room can be transformed in less than 60 seconds into an advanced imaging suite with a state-of-the-art, 1.5-tesla MRI scanner. As the sliding doors open, the 7.4-ton, ceiling-mounted mobile MRI scanner travels from the OR's adjacent docking bay to the patient, who is positioned on a stationary, hydraulically powered, cantilevered, titanium operating table (figures 1 and 2). After the bore is positioned around the patient like a doughnut by the nursing and anesthesia staff (figure 3), the MR technician begins the imaging process. With this advanced technology, the surgeons and radiologists, aided by the high-quality images, can decide whether further surgical interventions are needed before completing the operation and leaving the surgical suite.
View of the intraoperative MROR showing the magnet moving from the docking room
View of the intraoperative MROR showing the bore of the magnet positioned at the cantilevered titanium operating room bed
View from the docking room showing the ceiling-mounted magnet and the operating room
Once the imaging has been completed, the magnet is returned to the docking bay, the ceiling-mounted booms and equipment are moved back into place, and the operation continues as dictated by the imaging. The suite is then a full-service, standard operating room utilizing standard ferromagnetic surgical tools and instruments. No postoperative MRI in the radiology department—previously a standard procedure to confirm the effectiveness of neurosurgical interventions—is necessary. There also are no unnecessary return trips to the operating room for the patient, as the surgeon is assured that the operation was successful before leaving the OR. In short, the MROR provides the surgical team complete access to the patient and state-of-the-art equipment in a standard neurosurgery operating room, while converting to a diagnostic-quality MR imaging suite on demand.
“In addition to all the technical aspects of placing a mobile, 1.5-tesla MRI scanner in the middle of a modern OR, much time and effort were required of radiologists, radiologic technologists, surgeons, anesthesiologists, nurses, and other support staff in the OR to develop comprehensive operating procedures that would ensure that the MRI scanner could safely be operated when removed from its docking bay,” says Children's Hospital Boston's Director of Radiology Physics and Engineering Keith Strauss. “Any loose ferromagnetic object in the OR Suite—any item with iron content—instantly becomes a potentially lethal projectile when the MRI Scanner is removed from its docking bay. All persons entering this operating room, along with any items they might bring with them, must be tightly controlled.”
Technology as Catalyst
Supporting Children's Hospital Boston's mission to provide the most advanced pediatric healthcare and its commitment to push the boundaries in search of new and improved treatments, this innovative technology not only changed the future of brain surgery, but also drove the design process.
“As a neurosurgeon, being involved in the design of the operating suite from ground zero was a fascinating experience,” says Mark Proctor, MD. “We began the process with the structural requirements of the MRI unit front and center and built a modern OR around it.”
His colleague outlined the benefits. “This new intraoperative suite will result in safer and better surgery for kids who require brain surgery,” adds R. Michael Scott, MD, Chief of Neurosurgery at Children's Hospital Boston. “By being able to see images of the patient's brain in the midst of surgery, we can make certain that we have removed a tumor completely and save patients from having to return for additional surgery. This means better treatment and less discomfort for the child and more effective use of the surgical team's time.”
The MROR ensures unprecedented precision and verifies that the operation achieves the stated surgical objective. Nichole's case is a perfect example of how the new MROR can be used to benefit pediatric and adult patients.
Taking the Leap
The road to the MROR took several turns along the way as administrators, clinicians, and designers grappled with the challenges of researching, planning, and designing for the MROR. Once Children's Hospital Boston committed to integrating surgery with imaging, the design team was formed. A multidisciplinary user group of representatives from surgery and imaging visited other facilities to see how MRORs worked or didn't work, all the time wondering if this futuristic venture was real and what form it might take. During the initial planning and design, this major commitment took the collaborative efforts of a neurosurgeon, anesthesiologist, radiology physicist, nurse, administrator, facility planner, and architect.
The voyage began with a flight to Canada to view the prototype MROR at Foothills Hospital in Calgary. With such an investment at stake, exacting planning and design proved to be crucial and ended up bringing out the best in the institution and the design team through investigation, communication, and collaboration.
From a financial point of view, one might question such a large investment in technology. In fact, a review of the strategic plan indicated that the unit would probably never cover its development and operational costs. “Once the clinicians decided that this was the best system, and the multidisciplinary design team analyzed and proved that the constructability of the design was feasible, Children's Hospital Boston administration studied the business plan and found that the numbers did not support the return on this significant investment,” says Dr. Proctor. “However, they decided that this would be the best and only design for the MROR, moved forward, and funded the project, making a commitment and investment of more than $5 million to push the boundaries in search of new and improved treatments.”
The Planning and Design Process
Once the decision was made, the complex design process rapidly moved forward. First, the fundamental planning principle of designing a technologically adaptive building was critical to the successful incorporation of the MROR. Flexibility was paramount, to accommodate the size, weight, and technology of the MROR suite, its support area, and operations. In the initial stage of the building project, 1,500 square feet of shell space was located strategically to anticipate the MROR. Early considerations of circulation, access, adjacencies, and structure drove the location of the suite. Circulation paths and entry points were identified to allow patient routes from the prep/hold and PACU areas and the sterile surgical suite core, and elevators connected to the ICUs provided access for radiologists without their having to go through the sterile surgical suite (figures 4 and 5).
Floor plan showing the layout of the intraoperative MROR suite. Courtesy of Shepley Bulfinch Richardson and Abbott
Locus plan of perioperative services showing circulation. Courtesy of Shepley Bulfinch Richardson and Abbott
Based on the architecture firm's previous healthcare experience, they focused the design effort on the technical parameters for the installation of a standard MRI unit. Key factors for the MRI site planning included:
Transferring the magnet with a crane from the street through the removable panels in the building's unitized, glass curtain wall to the MROR;
Accommodating the proximity of the magnet iso-center to moving metals, such as, elevators, motors, cars, major electrical equipment, and cable. A “no-fly zone” was established;
Isolating vibration and sound;
Containing the five gauss line within the MROR; and
Designating the area for the MROR suite and magnet docking room that would work for future uses.
Initial programming and planning addressed future use of the space to allow for change. Options were developed so that the adjacent space could serve as OR storage, a second MROR, or an additional specialty operating room.
Simultaneously the team of engineers and consultants, including acoustic/vibration and radio-frequency (RF) shielding specialists, developed sophisticated vibration modeling and analysis. The architect and owner collaborated with the design team and IMRIS (Innovative Magnetic Resonance Imaging Systems, based in Winnipeg, Manitoba, Canada), which invented the concept of the moving magnet in an OR application. IMRIS provided and installed the system at Children's Hospital Boston, which incorporates a Siemens Symphony magnet with the largest commercially available bore.
Several design challenges had to be addressed before the installation. Because the MRI unit installed in the Children's Hospital Boston MROR slides along an overhead rail from its docking position in the third-floor OR, it initially was to be supported from the OR suite ceiling deck. At Children's Hospital Boston, however, as is the case at most hospitals, the OR is located beneath the fourth-floor mechanical room serving the building, with large air-handling units located directly over the OR suite.
Hanging a vibration-sensitive MRI scanner from the underside of a floor that supports large mechanical units required careful consideration. Despite highly efficient vibration isolators on the air-handling-unit fans, the acoustics consultant concluded that many potentially adverse conditions could compromise air-handling unit vibration isolation. Such compromises occur frequently but generally are not severe enough to interfere with usual OR operations. However, locating the MRI scanner below the air-handling unit posed a major challenge. The solution? Support the MRI unit on the third floor with structural bents that in turn support the overhead MRI rail.
“To control vibration transmission to the MRI unit, as well as to control the vibration that it produces to adjacent building spaces, three vibration-isolation techniques were employed,” explains Greg Tocci, president of Cavanaugh Tocci Associates, Inc., consultants in acoustics and vibration. “These included stiffening the floor slab in structural bays supporting the bent and rail assembly, installing specially designed pads at the bent attachments to the third-floor steel, and installing vibration-isolated restraints at the top of each bent that attaches to fourth-floor steel to control horizontal displacement of the bent structure on MRI acceleration and deceleration as the scanner travels along the overhead rail.”
Project development also required meetings during the design documentation and construction periods with IMRIS, the full design team, the construction manager and, often, with clinical users. Innovation in this first-of-its-kind construction, demanding problem solving, and coordination of trades took a huge team effort, but everyone was inspired by the client's mission and this unique opportunity.
During the development of the MROR, this innovative system also required a series of preemptive review meetings with the Commonwealth of Massachusetts Department of Public Health because exact regulations and guidelines that address these new technologies and clinical practices do not exist.
Special Design and Construction
To shield the MROR from extraneous RF interference that could have a negative impact on the imaging quality, the entire room was lined with copper sheeting (figure 6), which also electrically isolated the interior of the MROR from the outside world. All metal penetrations into the room had to go through RF waveguides or filters. In addition, the structure carried the ceiling-mounted magnet track to support the load of the magnet and prevent any deflection and movement that restrained the rolling magnet. Nonferrous materials were required within a 50-gauss-line field of the magnet. Acoustic considerations were addressed with an auto-seal door with special gasketing, silencers in ductwork, and double-wall acoustic sound insulation, so that the interior wall did not come into contact with the exterior wall assemblies. This isolation was needed to ensure that MRI vibration did not transmit sound to adjacent areas that included public spaces.
To shield the MROR from extraneous RF interference, the entire room was lined with copper sheeting, which also electrically isolated the interior of the MROR from the outside world
Special Safety Considerations
Patient and staff safety was the primary concern from day one. Entry to the room for surgery and imaging is limited to two doors: The patient has access from a sterile corridor, and equipment and clinicians, technicians, and staff have access from a restricted corridor. In addition, access into the room is controlled by interlinked magnetic locks and electromagnetic security passcards. The entry doors are linked to the doors of the magnetic docking room, and all entry from the substerile room is controlled by a charge nurse. Protocols and training have been a major initiative to ensure safe practice.
The Harmonic Blend
The new MROR at Children's Hospital Boston is a harmonic blend of multiple technologies. Through this collaboration of radiology, surgery, anesthesia, nursing, and design, the MROR has dissolved the line between surgery and radiology. No longer a futuristic fantasy, a state-of-the-art operating room can be transformed into a state-of-the-art imaging theater. As more advanced technology becomes available in healthcare, future healthcare and architectural teams can build on this innovative design model. HD
Charles Osborne, AIA, is a Senior Associate at Shepley Bulfinch Richardson and Abbott and a senior member of the firm's healthcare practice group. He specializes in the programming and design of pediatric healthcare facilities. In addition to Children's Hospital Boston, his clients include the Universidad de los Andes in Chile, Dana-Farber Cancer Institute, Yale-New Haven Hospital, and Hasbro Children's Hospital at Rhode Island Hospital. He received his Master of Architecture from the Graduate School of Design at Harvard University and was a Fulbright-Hays Fellow.
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The MROR Suite: The Facts
The 1,800 departmental-gross-square-foot, intraoperative MROR suite includes a standard, specialty operating room, adjacent docking room, scrub and substerile rooms, alcoves, and a control room that houses the MRI equipment cabinets and an electrical and fire protection closet. The adjacent OR storage room, not included in the square-foot total, is built with structural steel and frame to support a future MROR, or IT could also be converted into an additional specialty OR.
Owner: Children's Hospital Boston
Project: Clinical Building Expansion
Architecture: Shepley Bulfinch Richardson and Abbott
Mechanical/Electrical Engineering: Bard, Rao & Athanas Consulting Engineers
Structural Engineering: McNamara/Salvia, Inc.
Plumbing and Fire Protection: Robert W. Sullivan, Inc.
Acoustics Consulting: Cavanaugh Tocci Associates, Inc.
Equipment Consulting: C/W Design Group, Inc.
Construction Management: Macomber Builders
MRI System Provider: Innovative MRI Systems (IMRIS)
Radio-Frequency Shielding Consulting: ETS-Lindgren, Lindgren RF Enclosures, Inc.
Photography: Richard Mandelkorn
Healthcare Design 2006 May;6(3):56-62