Surgeons are clamoring for more operating rooms, and larger ones, to boot. Existing ORs are often in need of a major overhaul, and the luxury of new construction is rarely in the cards. What can you do to make renovation and expansion of the operating suite efficient and cost effective? Existing infrastructure, portable technology, and a trend toward hybrid ORs can all work to a facility’s advantage, as project teams dissect and reassemble the most revered real estate in any hospital.

But be prepared for multiple phases and disruption—lasting anywhere from six months to five years, depending on finances and end use—before cutting the ribbon on a new OR suite.

MEP drivers
While surgeons may have persuasive arguments for upgrading facilities, the phasing, depth, and breadth of an OR renovation may be determined by many factors not as visible to staff as the need for more space, for example. To start, the state of existing mechanical, electrical, and plumbing (MEP) and structural systems must be assessed.

The state of these systems will play a significant role in the phasing plan as well as the construction budget. Electrical and mechanical systems that are 15 to 20 years old are unlikely to meet current codes or to support present and future capacity. The 2014 Guidelines for Design and Construction of Hospitals and Outpatient Facilities now refer to the OR as a “wet room,” which means that isolation panels must be installed before any renovation, which increases electrical requirements. For example, if you’re building a hybrid OR that has imaging and interventional equipment in the room, such as catheter lab equipment, it will require additional cables, power, integration, and HVAC.

Structural support will also need to be added for lights, booms, and monitors, and the room will have to be expanded to accommodate this equipment. An older operating room may be 350 to 400 square feet, while new general ORs are between 500 and 600 square feet. Orthopedic and neurosurgical ORs are between 600 and 800 square feet, whereas a hybrid OR might be anywhere from 800 to 1,200 square feet. Those upgrades to the MEP infrastructure systems, which are the first step in the renovation, could be up to 50 percent of the construction cost.

Ceiling height also affects the mechanical systems in operating rooms. If you have 15 feet or more from floor to floor, the mechanical ducts aren’t limited in where they can be placed in the room. But if there’s a low floor-to-floor height (between 10 and 12 feet), the mechanical ducts won’t fit in the center of the room, making low soffits around the perimeter of the room necessary.

Low ceiling heights can also affect ceiling-mounted booms that support medical gases, power, data, monitors, and often shelves for small equipment. Locating the mechanical ducts and structural support for equipment booms can also be very challenging in low floor-to-floor heights.

One solution for this is to locate the structural supports for the booms on the sides of the ductwork for laminar flow above the OR table. For example, on one project, a low beam in the ceiling allowed hybrid OR equipment to pass but not the ductwork. The solution was to separate the air handlers and lights to operate on each side of the beam.

In another example, ductwork couldn’t be relocated, so a ceiling-mounted monitor was located at the end of the OR table with an extension arm. There was room for an anesthesia boom, but little else, so hose reels were used for electrical and medical gases, which require less space. Lights with extended arms to reach the OR table, including smaller monitors on the same arm, were also used.

When dealing with low ceiling heights, communication between the mechanical and structural engineers and the architect are crucial, as each situation will likely require a unique solution.

Streamlining the process
OR projects often require multiple phases and phasing plans—along with architectural and engineering plans. These plans must be approved by local and state agencies before any construction can take place. Phasing of the project should also be reviewed with the OR staff, facility manager, and by the project team to ensure all parties understand what moves and disruptions will take place and when they’ll occur.

Controlling dust and debris in operational ORs can be challenging during construction but not insurmountable. Preserving sterility inside the surgical suite is critical, so drywall partitions should be constructed in compliance with local infection control risk assessment standards. These standards are for the building and site areas that will be affected by construction and should include the determination of specific hazards and protection for each construction area.

Crews must be flexible in their work hours, because jackhammering won’t be tolerated during surgery. Because of this, construction will often occur during evenings and weekends, at an added cost.

In an ideal situation, the construction crew will be able to block off an area of the OR with a separate entrance and egress for materials and debris. If this isn’t possible, the construction crew will have to gown and cover all material going in or out of the OR.

During the time of construction, a third party or hospital engineer should monitor airflow regularly to prevent contamination. One helpful tactic is to look to adjoining soft space, such as an office or storage room, to explore an expansion.

For example, on one recent project, several unused preoperative holding bays located adjacent to an existing OR were used to create a new OR and avoid a shortage during renovation. In a second phase, two smaller existing ORs were converted into one right-sized space, with the addition of some core support.

Keys to success
In the end, renovation and upgrading of the OR or OR suite can best be accomplished with successful communication between the staff, the contractor, and the architecture/engineering team. This communication should occur throughout the renovation process. The more information the staff has, the fewer surprises there will be for the project team.

When operating rooms are upgraded to adequate square footage, and HVAC and structural requirements allow for advanced technology integration, surgeons will be able to perform day-to-day operations for complicated procedures in the safest environment for patients and staff.


Karan Hoffman is an architect and healthcare planner at EwingCole with over 30 years’ experience. She has designed operating suites for SUNY-Upstate, Paoli, Holy Spirit, Monongalia General, and other hospitals. She can be reached at