As a major source of revenue for healthcare systems, building adequate flexibility to accommodate multiple types of surgeries into today’s operating rooms is a big priority.

While features like larger rooms, interstitial floors, and surgical booms with articulating arms will help achieve this, they also all come with a high price tag. But Joseph Johnston Jr., principal at FreemanWhite (San Diego), estimates that each unavailable OR can cost a hospital at least $86,000 in daily revenue, so the extra investment in creating spaces to flex between uses inevitably pays for itself

Additionally, providers are looking to designers to help implement new trends like hybrid ORs, all while building environments that addresses both patient and staff satisfaction. It’s a tall order—but one that comes with plenty of reward.

The basics
When approaching OR projects, size is one of the first questions to answer. Mario Vieira, principal at Shepley Bulfinch (Boston), says increasing an OR beyond the 400-square-foot baseline is the most fail-safe investment in future flexibility. “The additional size is typically not needed as much for surgical staff workspace but more so for equipment and technologies that we can’t yet envision,” he says. Other healthcare designers recommend sizing today’s operating suites between 600 and 700 square feet, but not oversizing.

“Bigger isn’t necessarily better and one size doesn’t fit all,” Johnston says. “Longer staff travel distances are inefficient and may unnecessarily lengthen the duration of simple procedures and turnover time.” One strategy for limiting OR size is to provide for storage just outside the surgical suite. Not only is this adjacent space much less costly to build and operate, but such alcoves off the corridor are ideal parking spots for stretchers, mobile imaging equipment, and specialty carts, says John C. Schrott, president and managing principal Architect at IKM Inc. (Pittsburgh).

Designers also recommend including an interstitial floor space to avoid complications likely to arise with building systems maintenance, such as having to take ORs offline for HVAC repairs. “The cost of the infection control [measures] and phasing would exceed the value of the ventilation work,” Johnston says. Where interstitial floors aren’t an option, he suggests a minimum floor-to-floor height of 16 feet to provide vertical clearance for tall equipment, with at least 4 feet of above-ceiling space, the majority of which will be taken up by HVAC equipment to achieve the air flow levels required by these highly sterile environments.

To minimize trip hazards and enhance infection control, FreemanWhite prefers surgical booms to bring power, data, and medical gases closer to the patient. At the same time, when designing the structure and floor deck directly above an OR, it’s important to consider not only that floor’s structural loads but the suspended load of OR equipment, such as these booms, from below. “Organizing the framing members to follow a universal support grid facilitates anchorage of all overhead equipment from general surgery use to more complicated hybrid operating rooms or robotic environments,” Johnston says. “Lowering the primary structural floor deck six inches below the surrounding floor level in the operating rooms, clean core, and controlled corridors creates pathways for below-floor electrical ducts and future imaging modality needs.”

Richard S. McClelland, vice president of operations and principal architect for healthcare and senior living at Larson & Darby Group (Rockford, Ill.), recommends that a general structural support grid system be used in lieu of specific location equipment supports. This way, the OR can easily accommodate adding and relocating equipment.

Mixed methods
One major trend affecting the surgical landscape is the advent of hybrid ORs, which enable surgeons to perform intraoperative imaging while patients are on the operating table, potentially reducing the scope of surgery, recovery time, and the risk of infection. In fact, research, technology, and consulting firm Advisory Board Co. documents an increase from 50 to 250 nationwide hospitals incorporating hybrid ORs from 2008 to 2014, and OR Manager magazine projects a growth in hybrid ORs of 15 percent over the next decade.

While hybrids contribute significantly to enhanced patient care and delivery, the level of coordination required to set up one of these advanced spaces is tremendous. In addition to major infrastructure requirements, hybrids require the services of multiple vendors and consultants, making for a highly complex project process. While wiring, ductwork, conduit, and data don’t usually fall under the architects’ realm of expertise, the architect—as a surgical project’s prime consultant—inevitably serves as “air traffic controller” to manage details that fall between silos, according to FreemanWhite architect Jennifer Nussbaum.

For starters, architects should help end-users make equipment vendor decisions at the beginning of the design development phase. Because dimensions, clearances, and other requirements like power demand and heat generation will vary among medical equipment manufacturers, knowing these specifications will help the design team more accurately prepare their drawings.

Another big decision is whether a C-shaped arm that holds the X-ray will be attached to a standard mount or a flex mount. “A standard mount moves the C-arm along a narrower U-shaped track around the table and allows for the booms, lights, and monitors to be mounted closer to the table, which means shorter articulating arms,” Nussbaum explains. The flex mount is wider and affords more operational flexibility, but also requires more space. Nothing can be mounted between the tracks of the C-arm, essentially pushing the ceiling-mounted equipment further out, thereby requiring longer articulating arms.

If the hospital decides to go with a flex mount, this decision must be made early in the design process—even as soon as schematic design—or it may not be possible to secure enough space for the system.

“Since our designs are already very lean, especially given that a hybrid OR requires an equipment room and a control room, we don’t often have space to spare. Plus, depending on the equipment selected, the walls may need to be lead-lined,” Nussbaum says.

To help streamline this whole process, Nussbaum strongly recommends utilizing BIM so that consultants and vendors are all working off the same detailed model. Because a “change anywhere is a change everywhere,” any discrepancies or cost anomalies can be addressed in real time, and potential clashes can be detected and resolved prior to construction. FreemanWhite uses BIM to coordinate the conduit, support structure, and mechanical and lighting systems for medical equipment, thereby expediting shop drawings, construction scheduling, and equipment installation.

Adjacencies and patient flow
To reduce the amount of time patients spend in ORs, institutions must also optimize patient flow through the pre-op and post-op zones. To start the process, Larson & Darby works with hospital staff to ensure all major departmental adjacencies are well thought out. Next, block diagrams are used to illustrate patient, staff, and process flow, along with required functional adjacencies, according to Timothy Gaumond, director of healthcare at Larson & Darby.

Putting this into action for the recent design of a 12-room orthopedic operating room suite,
IKM outfitted four ORs with a staging room to prep the next round of surgeries with equipment on tables, ready to roll out, thereby minimizing OR turnover time. Optimizing patient flow, BWBR Architects (St. Paul, Minn.) designed the pre-op rooms for Hennepin County Medical Center’s ambulatory care facility in Minneapolis with doors on opposite walls so that family members can be escorted back to the waiting room, while the patient continues on to the OR through the other door. Similarly, the OR is outfitted with two rooms so that the outgoing patient can exit through one door while the next surgery patient enters through the other door.

In terms of adjacencies for a typical project, FreemanWhite places the post-anesthesia care unit (PACU) immediately adjacent to the ORs, with the prep/recovery areas positioned on the other side of a public corridor, but still adjacent to the ORs.

By incorporating a back-of-house horizontal adjacency between the ED and surgery, this reduces travel time for critically ill ED patients. In cases where vertical adjacency is the only option, FreemanWhite Principal David Martin says elevators must be large enough to accommodate a stretcher, life support equipment, and two or more staff members.

While many labor and delivery units have their own C-section rooms, often obviating the need for a direct adjacency, in some cases (for example, rural locales), patient volumes may not justify this, according to Scott Holmes, associate principal of medical planning at BWBR Architects. “There’s no one-design-fits-all answer to optimizing patient flow in facilities as both market conditions and the size of scope of the facility can influence the design,” he says.

For example, David Meek, an associate at Shepley Bulfinch, relates that on one project, his firm integrated the C-section room with the inpatient operating rooms so that the hospital only had to operate one surgical environment with anesthesia and other support staff rather than be spread across the hospital, as is the case with traditional floor plans.

Recovery areas
Another key aspect of surgical suite design is setting up the recovery spaces to support patient comfort and privacy. However, these areas can be arranged in a variety of ways, each with pros and cons. “Patients and families are more comfortable and post higher satisfaction scores in private rooms, but curtained bays offer greater flexibility for shared use between different patient types,” says FreemanWhite Healthcare Planner Minta Ferguson.

However, if the bays are to flex with PACU, then they must be constructed to the more stringent requirements of a PACU. In addition, hospitals may want the flexibility to use the bays as a surgery prep area, but then the design must accommodate a higher level of patient privacy to conform with HIPAA regulations. A third option is recliner recovery stations—either within curtains or private rooms—which offer privacy in a smaller space but provide less flexibility, as their size limits future use with stretchers or beds.

As an example, FreemanWhite designed the prep/recovery/PACU area for the Saint Thomas Joint Replacement Institute in Nashville, Tenn., to accordion up and down based upon patient type, acuity, and time of day. The need for this level of flexibility ultimately determined the design requirements for the entire unit. In particular, the recovery bays were set up with three walls and a curtain in front. “As far as privacy is concerned, we’ve been going with three- and four-wall bays rather than traditional curtains, and that means bigger bays,” reports Shepley Bulfinch associate Srey Sherman. “This way we can address the need for family space and room for nurses to move around.”

In considering staff efficiency and patient sightlines, code dictates that nurses must have a direct visual connection to each patient. This can be achieved by decentralized nurses’ stations or workstations on wheels that can be brought to the bedside or docked between patient rooms.

Doing it right
To create a successful OR experience, two user groups must be considered: the staff and the patients.

“I have found that no single activity is more informative to the planning and designing of new facilities than shadowing key personnel in the operating theater. The interaction of the team during a case is seldom caught with the static drawing of the floor plan with idealized equipment placement. Only after observing cases from start to finish will designers truly understand how to best design toward the complexity of these demanding suites.”

For patients, designers should start from the parking lot and design the navigation route through the facility on into surgery to ensure the intended experience is achieved. “Until one has experienced this firsthand, one will not realize the impact of elements like lighting, color, temperature, and ambience that impact patients as well as caregivers,” Meek says.

By achieving this ideal experience for staff and patients and partnering it with a design that facilitates streamlined prep, surgery, and recovery operations, organizations stand to see the benefits from investments made to the environments that facilitate one of the highest revenue-generating area in any hospital. 


Barbara Horwitz-Bennett is a contributing editor for Healthcare Design. She can be reached at