THE OPERATING ROOM OF THE FUTURE
Surgery is being revolutionized. For example, minimally invasive surgery has yielded dramatic benefits, including shorter recoveries and fewer complications. Robotic surgery is improving surgeons’ consistency and reducing fatigue. Invasive cardiology is restoring normal life to patients who would have died from heart attacks only a few years ago. Like many other advances now appearing in surgical suites, these technologies are changing the form and function of physical space and are being examined under a new rubric, the operating room of the future (ORF).
Traditional boundaries of surgical space will blur as computer-enhanced technologies allow surgeons to perform more procedures in distant, virtual environments. The ORF will use “smart” software and other tools of knowledge management to link clinical care directly with electronic medical records and operational (e.g., inventory, finance) information systems.
Advanced devices that extend surgeons’ technical capabilities, such as robotic surgery systems and image-guided technologies used in minimally invasive surgical procedures, are emerging and creating new space-planning challenges. For example, a surgeon can use video endoscopy or open-magnet MRI to visualize organs on an external display, in contrast to direct visual and physical examination associated with open surgery. Computer-controlled surgical robots, using a mechanical arm and detachable instruments, can enhance a surgeon's capabilities to perform precise and repetitive motor movements (e.g., dissection, suturing). High-tech navigational tools to guide the surgeon to the closed operative area are also beginning to gain acceptance.
The registration (i.e., visual merger) of real-time ultrasound images and preoperative three-dimensional data from CT or MRI scans offers promise to provide acceptable virtual images of internal tissue without opening the body. Robotic visualization devices and surgical robots are currently used for procedures such as gastric bypass, radical prostatectomy, arthroscopy, and placement of epicardial pacemaker leads. The technology is even being applied to cardiac surgery on an investigational basis.
Space planners and designers should expect growing use of voice-controlled workstations and devices, holographic and microdisplay technologies, and next-generation imaging devices, such as open-magnet MRI and Doppler ultrasound. Complementary therapies (e.g., biofeedback, acupressure, acupuncture, heat therapy, and aromatherapy) may also become common in the surgical suite, and require space accordingly, as more patients elect to remain conscious during their minimally invasive procedures.1
Acceptance of telemedicine in surgery is growing.2 Integrated telecommunication systems that combine voice, data, and images are being coupled with digital information systems (e.g., radiology, laboratory, or patient-monitoring systems) and computer-enhanced medical technologies to enable real-time collaboration for remote procedures, consultation, and distance teaching. Indeed, remote-controlled robots create the possibility of removing the surgeon from the operating room altogether. The need to design optimal space for “remote surgeons” may become commonplace in just a few years.
Available technology can already create interactive environments that allow collaboration among clinicians who are present in the operating suite, remote surgical consultants, perioperative support staff (e.g., information technicians), and distance-learning students. Telesurgery does raise ethical, legal, and clinical concerns, however, that will need to be resolved before its adoption becomes widespread.
Electronic medical records interfaced with other clinical information systems (e.g., pharmacy, radiology, laboratory) will allow immediate access to patient data for all authorized caregivers. Voice-activated systems will become a standard method for medical information retrieval and documentation.
Patient flow will be improved by new communications software and electronic patient tracking systems that disclose a patient's status throughout the perioperative process. These systems will not only enable real-time monitoring and intrateam communication of patient data, but they also will assist management in real-time review of data to improve the patient flow process and the overall cost-effectiveness of care.
Implications for Facility Design
Increasing reliance on biomedical and information technology within the surgical suite will significantly impact architectural and engineering design and related planning for equipment, infrastructure, and applications:
Space. The trend to create universal operating rooms will continue for high-tech, specialty surgery (e.g., cardiology, neurology, orthopedics). Technology within the operating room (e.g., video endoscopy, robotics, mobile ultrasound) will generally require suites of 550 to 650 square feet. The use of retractable, ceiling-mounted booms or docking stations to organize technology and utilities efficiently and to maximize floor space will become commonplace in the ORF.
As video technology and medical informatics expand, boundaries between traditional imaging areas and operative suites will blur. Adjacent control rooms may need to be created to accommodate remote consoles for image-guided, computer-assisted surgical procedures. Although more fixed imaging equipment may be installed in surgical suites in the near term, future advancements in image acquisition and software modeling will likely reduce the need to install larger imaging equipment (e.g., CT, MRI) within the suite.
For the short term, hospitals driven by high capital costs of new technologies and standby requirements for complex outpatient procedures (e.g., angioplasty) may focus on designing combined inpatient/outpatient surgical settings. Ultimately, however, advances in robotics and nanotechnologies will allow minimally or noninvasive procedures to be performed in the physician's office.1 In the more distant future, therefore, hospitals could face having to retrofit procedure rooms for other uses, such as patient education or rehabilitation.
Medical equipment. As noted, next-generation OR equipment will be digital, networked, and controlled by voice. In addition to the surgical table and lights, a universal operating room of the future will be equipped with devices for video endoscopy and telesurgery. Ubiquitous access to computers will take various forms, from desktop computers to mobile laptops to handheld personal digital assistants (PDAs), and monitors will include ceiling-mounted flat screens, virtual headsets, and special eyeglasses that superimpose images on their lenses. New space-planning and infrastructure challenges will follow, such as measures to eliminate distractions from reflected light, determine optimal distances between viewers and displays, provide power sources to recharge batteries, and meet the technical requirements of different wireless interfaces.
IT infrastructure and applications. The ORF will be a fully integrated digital environment, enabling easy and immediate access to specialized databases and digital equipment. This specification will require connectivity with adequate bandwidth to transport multiple data formats in real time. In contrast to the current situation, in which vendors commonly offer information systems that do not interface well with other systems, standardized components will become the norm in surgical-suite technology infrastructure—interoperable, scalable, and Internet-enabled for “plug and play” functionality. In the near term, Web services and other “middleware” interfaces will increasingly support data sharing among the operating room information system, the hospital information system, and clinical information systems.
Telecommunications. The ORF will require both wired and wireless telecommunications systems for at least the next few years. Wireless connectivity will allow the use of handheld or wearable devices for order entry and access to online information (e.g., multimedia electronic patient records). Hard-wired connectivity will likely be needed to transport data and images within the surgical service and to remote sites for videoconferences, but radio-frequency (RF) and light-based (e.g., infrared) wireless technologies may someday replace most cabling. Design professionals will need to master the technical requirements of connectivity for wireless communications in order to support systems integration.
Building systems. Smart-building technologies will be incorporated into ORF designs to manage climate, lighting, security, and fire alarm systems. More electrical power and more robust information technology infrastructure will be needed to handle the escalating requirements of these support systems. Moreover, ventilation to remove heat from solid-state components will also become more important with the proliferation of digital devices.
Conclusions and Implications
The ORF will be designed to deliver an efficient, safe, and positive experience for patients and clinicians. Although enabling developments in technology and informatics will occur over several years, related strategic planning should be initiated now to assess the current environment, evaluate trends, and develop purposeful responses. ORF design and development strategies should be closely linked to capital planning, governance and leadership, operations redesign, clinical transformation management, acquisition and/or upgrading of clinical information systems, research and evaluation activities, and staff education and development programs.
Such integration is necessary because the remarkable advances in technology discussed here will continue to transform surgical care and its environment. Healthcare systems will be increasingly challenged to invest enough capital in ORF projects to remain state of the art while setting aside sufficient funds for adapting to the ongoing evolution in supportive technology. A particular challenge for designers and architects will be to create “just enough” flexible operating room capacity, with a robust information system infrastructure, to adapt readily to the technologic revolution that is already under way and moving rapidly in directions that are not completely predictable. HD
Jeffrey C. Bauer, PhD, a nationally recognized medical economist and health futurist, is Senior Vice-President, and Jeni Wright, RN, AIA, a nurse and architect, is a senior management consultant with Superior Consultant Company, Inc., of Southfield, Michigan.
- Gallo S. Surgery in the Twenty-first Century Surgical Services Management 1999; 5 (2): 18-21
- Demartines N., Freiermuth O., Mutter D., et al. Knowledge and acceptance of telemedicine in surgery: A survey Journal of Telemedicine and Telecare 2000; 6 (3): 125-31