Tight Fit: Designing A Hybrid OR In Limited Square Footage
Outfitted with a full complement of operating room (OR) equipment plus state-of-the-art imaging technology, hybrid operating rooms are allowing surgeons to diagnose and pinpoint problems while patients are on the table—and make immediate adjustments to a treatment plan based on what they see on-screen. And for cardiac patients with no other options for recovery than transaortic valve replacement (TAVR) surgery, hybrid ORs can provide the ideal space to perform the lifesaving procedure.
As early as 2007, the benefits of a hybrid OR were clear to Dr. Frederick Grover, chair of surgery at the University of Colorado School of Medicine (Aurora, Colo.). With TAVR still in clinical trials—and the University of Colorado Hospital (UCH) preparing to open a new facility—Grover stopped construction of two ORs and had the existing space designed to be a potential hybrid OR. Dr. David Fullerton, professor of cardiothoracic surgery at UCH, had also been monitoring how surgery procedures might change and supported the move, while acknowledging the arguments of internal naysayers. “To designate precious OR space—very valuable to a hospital—to something unproven required a certain amount of faith,” he says. “So it was appropriate to be thoughtful about it, and we were.”
Two major factors eventually drove the decision to proceed: FDA approval of the TAVR procedure and the hybrid OR’s potential for improved patient care. Once funding for the project was committed in spring 2010, UCH began working closely with architectural and engineering firm Leo A Daly (Omaha, Neb.)to design a hybrid OR within the prebuilt space that was serving as a traditional operating room in the interim.
Give and take
Key to the planning effort was the willingness of all involved—doctors, nurses, administrators, technicians, and designers—to determine together what the room needed to function most efficiently. “Each group got along fine in the environment they were accustomed to, but here they needed to work jointly with other groups,” says OR Nurse Manager Suzanne Sortman, who oversees 75 nurses and 30 techs. “So we set the expectation that no matter what your area of expertise or your level of responsibility, you attended meetings and you had a voice. And it worked. But it would not have worked without that kind of collaboration,” she says.
Adds Dr. Brett Reece, UCH assistant professor of cardiothoracic surgery and chair of the hybrid OR committee, “We wanted to best use advanced technologies to provide optimal care, and we needed to teach and conduct research, as well. To have a comprehensive program and take care of every kind of patient issue, many skills are needed, so our decisions needed to reflect each area of expertise.”
With collaboration a given, the group’s next challenge proved to be choosing equipment that functioned ideally for every person working in the room. Several of those involved made site trips to the very few hybrid ORs already in operation. For example, Fullerton and Katherine Halverson Carpenter, UCH patient care services director, evaluated operating tables, imaging systems, and lighting gantries in the U.S. and abroad. After seeing each in action, they selected those flexible enough to accommodate the variety of procedures the operating room would host.
Putting ideas in place
Once UCH staff agreed on the ideal equipment for the room, designers began creating options for the most efficient room layout for its 750 square feet, working with equipment manufacturers, UCH Facilities Project Manager John Backus, and building information modeling software to provide precise clearances. First the team placed a huge C-arm, which is used to deliver fluoroscopic images and is set in a track so it can be moved back and forth and circle the operating table. A table specifically designed for the hybrid OR with interchangeable tops was positioned next; one top can slide back and forth and side to side, allowing the C-arm to get the best possible images, and the other can be used for traditional OR procedures. Big-screen, 55-inch monitors were placed tableside, and a broadcast-quality camera was mounted on the ceiling. The perimeter of the room is lined with anesthesiology and perfusion equipment, as well as several computers and equipment that allows interfacing between the room’s multiple systems. “Our goal was to maximize space around the surgical table,” Backus says. “In this existing space, it was a very tight squeeze, and some physical changes were necessary.” One such change involved ripping out existing flooring—grinding down high spots and filling in low spots—to accommodate the C-arm, which had to roll on a perfectly level floor. “Typically, buildings are not constructed to the level of tolerance required by this piece of equipment,” Backus says.
The square footage didn’t leave room for a swinging door, either—it would have hit the perfusionist. So a sliding door was necessary, but it had to be lead-lined and smoke-rated, which pushed its weight to 700 pounds. “It took a very large beam over the door header to support it,” says Bob Mussack, Leo A Daly medical equipment planner. “And because scrubbed clinicians can’t back through a sliding door to stay sterile, a standard-height push plate was installed as well as a foot-operated one.”
Debuting in April 2012 as only the sixth of its kind in the country and an FDA beta test site, the UCH hybrid OR saw 330 hybrid cases in its first year of operation—62 of them TAVRs—and now welcomes patients from Colorado and its surrounding states. Demand for the room’s capabilities is so strong from vascular, gynecological, interventional radiology, TAVR, aortic/thoracic, and electrophysiological surgeons that a second hybrid OR is under consideration at the facility. When the design team conducted a post-occupancy evaluation of the room, one of the key learnings involved planning for the possibility of two hybrid ORs flanking a single control room. “Even when clients have space for only one hybrid OR, we now recommend placing the control room on the side of the room where there may be potential for expansion or where space might be reallocated,” says Debra Sanders, director of healthcare development for Leo A Daly. “That way, one control room can serve two hybrid ORs should it become necessary.”
The ideal size and shape of the UCH hybrid OR also became apparent as it saw constant use. Jeff Monzu, Leo A Daly’s vice president of medical planning, says that while 750 square feet is clearly working, up to 1,000 square feet would be better. He also notes that the room might best be designed as a square rather than a rectangle, to provide more storage area for carts and mobile equipment in the support spaces around the table. “This kind of configuration also accommodates more people,” Monzu says. “In a hybrid OR, there can be up to 30 people in the room during a procedure, especially in a medical center like UCH, where training takes place.”
The ceiling of the hybrid OR is also important to the room’s success. To provide UCH flexibility in repositioning lighting booms should the need arise, engineers designed a special gasket/grid system with clean-room-rated lay-in tiles. “The design and materials make it easy to access and clean the ceiling without tearing into drywall and shutting the OR down for an extended period of time,” says equipment
Despite the challenges inherent in designing within a prescribed space, the UCH OR continues to capably handle the steady traffic and varied procedures required of it. “No one is ever going to say it should be smaller,” says Dr. John Messenger, UCH director of cardiac catheter labs and TAVR surgeon. “We’re practiced at these procedures, and personally I think there’s plenty of room. The hybrid OR is successful in giving patients renewed lives. As surgeons, that’s what we’re all about.”
This is the second part of Healthcare Design’s three-part special report on hybrid operating rooms. To read the first installment, visit http://www.healthcaredesignmagazine.com/article/redefining-operating-room. To read the third installment, visit http://www.healthcaredesignmagazine.com/article/akron-general-layers-technology-hybrid-or-suite.
Lighting is a critical component of the hybrid operating room, where complicated procedures take place every day, but design and installation comes with plenty of challenges. For example, lighting can easily collide with the hybrid OR’s large monitors. There’s also more HVAC and electrical infrastructure in the ceiling, such as air curtain ventilation directly above the operating table, that limits where the lighting booms can be installed. Positioning of booms might also change depending on the height of surgeons working side by side—one perhaps throwing a longer shadow—or with each type of procedure.
“Lighting in this room is a constant choreography,” says Dr. Omid Jazaeri, UCH assistant professor of vascular surgery. “We knew, for instance, when we chose a ceiling-mount lighting system, that it would be an issue when the boom crosses paths with the C-arm. A floor-mount might allow a tight focus on one area, which is preferable for most surgeons. But as a vascular surgeon, I do work all over the body, and it’s challenging to focus light—and radiation—on all of the extremities. So the position of the light source must keep changing.”
Kelly Carman, Leo A Daly lighting engineer, says ceiling-mount lighting was the only real choice for the UCH hybrid OR because floor space was limited and already in use by other vital equipment—and people. “Where space is at a premium, ceiling-mount equipment is the only real option,” he says. “But lighting manufacturers are constantly designing more flexibility into their systems, and it’s likely that a boom may operate differently than it did in a previous iteration. So product research and communication with manufacturers are key.”
Owner: University of Colorado Hospital
Completion date: April 2012
Architecture and engineering: Leo A Daly
Interiors: Gallun Snow
MEP: BCER Engineering
Operating table: Maquet